Provider Demographics
NPI:1912545955
Name:RURAL PRIMARY CARE SOUTH-WALTON, INC.
Entity Type:Organization
Organization Name:RURAL PRIMARY CARE SOUTH-WALTON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:850-420-5420
Mailing Address - Street 1:5551 US HIGHWAY 98
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459
Mailing Address - Country:US
Mailing Address - Phone:850-420-5420
Mailing Address - Fax:850-244-8011
Practice Address - Street 1:5551 US HIGHWAY 98
Practice Address - Street 2:SUITE 2
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459
Practice Address - Country:US
Practice Address - Phone:850-420-5420
Practice Address - Fax:850-244-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-19
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110818301Medicaid