Provider Demographics
NPI:1922099928
Name:PHC-FT WALTON INC
Entity Type:Organization
Organization Name:PHC-FT WALTON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:AROL
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:850-863-2066
Mailing Address - Street 1:909 GARDENGATE CIR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504
Mailing Address - Country:US
Mailing Address - Phone:850-479-1012
Mailing Address - Fax:850-479-1013
Practice Address - Street 1:1 L B J SR DR
Practice Address - Street 2:
Practice Address - City:FT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1163
Practice Address - Country:US
Practice Address - Phone:850-863-2066
Practice Address - Fax:850-863-9006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL14605314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022923700Medicaid
FL4356260001Medicare NSC
FL022923700Medicaid