Provider Demographics
NPI:1013059922
Name:WAKULLA COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:WAKULLA COUNTY HEALTH DEPARTMENT
Other - Org Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:ACTING ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-926-3591
Mailing Address - Street 1:48 OAK STREET
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32327
Mailing Address - Country:US
Mailing Address - Phone:850-926-3591
Mailing Address - Fax:850-926-1938
Practice Address - Street 1:48 OAK ST
Practice Address - Street 2:
Practice Address - City:CRAWFORDVILLE
Practice Address - State:FL
Practice Address - Zip Code:32327-2085
Practice Address - Country:US
Practice Address - Phone:850-926-3591
Practice Address - Fax:850-926-2178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33253Medicare ID - Type UnspecifiedHEALTH DEPARTMENT