Provider Demographics
NPI:1073842456
Name:ESCAMBIA COMMUNITY CLINICS INC
Entity Type:Organization
Organization Name:ESCAMBIA COMMUNITY CLINICS INC
Other - Org Name:12TH AVENUE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMILEY
Authorized Official - Suffix:
Authorized Official - Credentials:EXECUTIVE DIRECTOR
Authorized Official - Phone:850-436-4630
Mailing Address - Street 1:2315 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-7552
Mailing Address - Country:US
Mailing Address - Phone:850-436-4630
Mailing Address - Fax:850-436-2095
Practice Address - Street 1:2510 N 12TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503
Practice Address - Country:US
Practice Address - Phone:850-471-0508
Practice Address - Fax:850-471-0510
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESCAMBIA COMMUNITY CLINICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-15
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692990705Medicaid
FLH12128Medicare UPIN
FL42380YMedicare PIN