Provider Demographics
NPI:1710984299
Name:HEALTHMARK OF WALTON INC
Entity Type:Organization
Organization Name:HEALTHMARK OF WALTON INC
Other - Org Name:HEALTHMARK REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:SHIRLEY
Authorized Official - Last Name:HOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-951-4500
Mailing Address - Street 1:4413 US HIGHWAY 331 S
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-6307
Mailing Address - Country:US
Mailing Address - Phone:850-951-4500
Mailing Address - Fax:850-892-7079
Practice Address - Street 1:4413 US HIGHWAY 331 S
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-6307
Practice Address - Country:US
Practice Address - Phone:850-951-4500
Practice Address - Fax:850-892-7079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4234282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010188500Medicaid
77860Medicare PIN
FL100081Medicare Oscar/Certification
FL010188500Medicaid
FLCH9245Medicare PIN
CE1575Medicare PIN
FL0963390001Medicare NSC