Provider Demographics
NPI:1518712728
Name:SOUTHERN SHORES FAMILY WELLNESS
Entity Type:Organization
Organization Name:SOUTHERN SHORES FAMILY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHHOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:BILLER
Authorized Official - Phone:850-358-6290
Mailing Address - Street 1:1606 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-1908
Mailing Address - Country:US
Mailing Address - Phone:850-896-7616
Mailing Address - Fax:
Practice Address - Street 1:1606 W 10TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-1908
Practice Address - Country:US
Practice Address - Phone:850-896-7616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care