Provider Demographics
NPI:1013908201
Name:HEALTHMARK OF WALTON RURAL HEALTH CLINIC INC
Entity Type:Organization
Organization Name:HEALTHMARK OF WALTON RURAL HEALTH CLINIC INC
Other - Org Name:HEALTHMARK CLINIC
Other - Org Type:Other Name
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:850-951-4507
Mailing Address - Street 1:4415 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:850-951-4640
Mailing Address - Fax:850-892-7079
Practice Address - Street 1:4415 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:850-951-4640
Practice Address - Fax:850-892-7079
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHMARK OF WALTON INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-04
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372384401Medicaid
FL372384401Medicaid
FL39842Medicare PIN