Provider Demographics
NPI:1689864035
Name:ESCAMBIA COMMUNITY CLINICS, INC
Entity Type:Organization
Organization Name:ESCAMBIA COMMUNITY CLINICS, INC
Other - Org Name:SANTA ROSA COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-436-4630
Mailing Address - Street 1:2315 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-7552
Mailing Address - Country:US
Mailing Address - Phone:850-436-4630
Mailing Address - Fax:850-436-2095
Practice Address - Street 1:6671 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-4781
Practice Address - Country:US
Practice Address - Phone:850-981-9433
Practice Address - Fax:850-981-9436
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESCAMBIA COMMUNITY CLINICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-31
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692990702Medicaid
FL692990702Medicaid