Provider Demographics
NPI:1477738896
Name:NORTH OKALOOSA CLINIC CORP
Entity Type:Organization
Organization Name:NORTH OKALOOSA CLINIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-7626
Mailing Address - Fax:615-465-3007
Practice Address - Street 1:550 REDSTONE AVE W
Practice Address - Street 2:STE. 370
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6428
Practice Address - Country:US
Practice Address - Phone:850-682-2209
Practice Address - Fax:850-682-2528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6060550001Medicare NSC