Provider Demographics
NPI:1225634462
Name:BEACHSIDE PEDIATRIC ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:BEACHSIDE PEDIATRIC ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:COVELL
Authorized Official - Last Name:LANCASTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-758-8331
Mailing Address - Street 1:1590 RUCKEL DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1603
Mailing Address - Country:US
Mailing Address - Phone:850-621-5058
Mailing Address - Fax:
Practice Address - Street 1:490 HIGHWAY 85 N
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1010
Practice Address - Country:US
Practice Address - Phone:850-419-2691
Practice Address - Fax:850-353-2142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-10
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care