Provider Demographics
NPI:1407301757
Name:GULF COAST ADDICTION MEDICINE
Entity Type:Organization
Organization Name:GULF COAST ADDICTION MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-522-1516
Mailing Address - Street 1:277 FOREST PARK CIR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4920
Mailing Address - Country:US
Mailing Address - Phone:850-522-1516
Mailing Address - Fax:850-522-1518
Practice Address - Street 1:277 FOREST PARK CIR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4920
Practice Address - Country:US
Practice Address - Phone:850-522-1516
Practice Address - Fax:850-522-1518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0301251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health