Provider Demographics
NPI:1811457716
Name:PROGRESSIVE HEALTH CLINIC, LLC
Entity type:Organization
Organization Name:PROGRESSIVE HEALTH CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:A
Authorized Official - Last Name:GODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-374-3926
Mailing Address - Street 1:29G MIRACLE STRIP PKWY SW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-6655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29G MIRACLE STRIP PKWY SW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-6655
Practice Address - Country:US
Practice Address - Phone:334-437-4308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-25
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center