Provider Demographics
NPI:1740644202
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 EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOZAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-415-8103
Mailing Address - Street 1:1376 BRICKYARD RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-6391
Mailing Address - Country:US
Mailing Address - Phone:850-638-0552
Mailing Address - Fax:850-638-0504
Practice Address - Street 1:1376 BRICKYARD RD
Practice Address - Street 2:SUITE 4
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-6391
Practice Address - Country:US
Practice Address - Phone:850-638-0552
Practice Address - Fax:850-638-0504
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST FLORIDA HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108943Medicare Oscar/Certification