MEDICARE: CAMPBELLTON-GRACEVILLE HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	275N00000X	Medicare Defined Swing Bed Hospital Unit	4172	FL

General Provider Information

NPI Number	:	1942417316
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMPBELLTON-GRACEVILLE HOSPITAL

Provider Business Mailing Address
First Line	:	5429 COLLEGE DR
Second Line	:
City	:	GRACEVILLE
State	:	FL
Zip	:	32440-1857
Country	:	US
Telephone Number	:	850-263-4431
Fax Number	:	850-263-3312

Provider Business Practice Location Address
First Line	:	5429 COLLEGE DR
Second Line	:
City	:	GRACEVILLE
State	:	FL
Zip	:	32440-1857
Country	:	US
Telephone Number	:	850-263-4431
Fax Number	:	850-263-3312

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MS. DENA R COOPER
Credential	:
Telephone Number	:	850-263-4431

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	08/22/2020

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