Provider Demographics
NPI: | 1265668511 |
---|---|
Name: | TAMMY KALIKO WILLINGHAM, INC. |
Entity Type: | Organization |
Organization Name: | TAMMY KALIKO WILLINGHAM, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | TAMMY |
Authorized Official - Middle Name: | KALIKO |
Authorized Official - Last Name: | WILLINGHAM |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MA/SLP/CCC |
Authorized Official - Phone: | 321-984-2789 |
Mailing Address - Street 1: | 151 TERRACE SHORES DR |
Mailing Address - Street 2: | |
Mailing Address - City: | INDIALANTIC |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32903-2705 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 321-984-2789 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 151 TERRACE SHORES DR |
Practice Address - Street 2: | |
Practice Address - City: | INDIALANTIC |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32903-2705 |
Practice Address - Country: | US |
Practice Address - Phone: | 321-984-2789 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-06-01 |
Last Update Date: | 2009-06-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | SA8192 | 302F00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 302F00000X | Managed Care Organizations | Exclusive Provider Organization |