Provider Demographics
NPI:1891862322
Name:SUNCOAST HEALTHCARE PROFESSIONALS
Entity Type:Organization
Organization Name:SUNCOAST HEALTHCARE PROFESSIONALS
Other - Org Name:HEALTHSOURCE OF FORT WALTON BEACH SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SWISHER-LEATHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-864-5300
Mailing Address - Street 1:431 E HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-2058
Mailing Address - Country:US
Mailing Address - Phone:850-864-5300
Mailing Address - Fax:
Practice Address - Street 1:431 E HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-2058
Practice Address - Country:US
Practice Address - Phone:850-864-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8740111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty