Provider Demographics
NPI:1043596091
Name:NORTHWEST FLORIDA DIABETES & NUTRITION CENTER, LLC
Entity Type:Organization
Organization Name:NORTHWEST FLORIDA DIABETES & NUTRITION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:850-482-1830
Mailing Address - Street 1:PO BOX 1854
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-7854
Mailing Address - Country:US
Mailing Address - Phone:850-482-1830
Mailing Address - Fax:
Practice Address - Street 1:120 W WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-3527
Practice Address - Country:US
Practice Address - Phone:850-482-1830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-21
Last Update Date:2014-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service