Provider Demographics
NPI:1578618104
Name:ALL SEASONS ALLERGY AND ASTHMA CENTER, P.A.
Entity Type:Organization
Organization Name:ALL SEASONS ALLERGY AND ASTHMA CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-862-3020
Mailing Address - Street 1:362 BEAL PKWY NW STE 105
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-3926
Mailing Address - Country:US
Mailing Address - Phone:850-862-3020
Mailing Address - Fax:850-862-1363
Practice Address - Street 1:362 BEAL PKWY NW STE 105
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-3926
Practice Address - Country:US
Practice Address - Phone:850-862-3020
Practice Address - Fax:850-862-1363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9224207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI01436Medicare UPIN