Provider Demographics
NPI:1134422470
Name:NORTHWEST FLORIDA HEALTHCARE, INC.
Entity type:Organization
Organization Name:NORTHWEST FLORIDA HEALTHCARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LISENBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-415-8107
Mailing Address - Street 1:3250 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:FL
Mailing Address - Zip Code:32462-2223
Mailing Address - Country:US
Mailing Address - Phone:850-535-2096
Mailing Address - Fax:
Practice Address - Street 1:3250 MAIN ST
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:FL
Practice Address - Zip Code:32462
Practice Address - Country:US
Practice Address - Phone:850-535-2096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty