Provider Demographics
NPI:1457446387
Name:NICEVILLE PRIMARY CARE BLUEWATER
Entity Type:Organization
Organization Name:NICEVILLE PRIMARY CARE BLUEWATER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-523-2117
Mailing Address - Street 1:4400 E HIGHWAY 20
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8779
Mailing Address - Country:US
Mailing Address - Phone:850-897-3678
Mailing Address - Fax:850-897-3708
Practice Address - Street 1:4400 E HIGHWAY 20
Practice Address - Street 2:SUITE 203
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8779
Practice Address - Country:US
Practice Address - Phone:850-897-3678
Practice Address - Fax:850-897-3708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAB478Medicare PIN