Provider Demographics
NPI:1912271701
Name:FLORIDA DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:LIBERTY COUNTY HEALTH DEPARTMENT/LIBERTY COMMUNITY HEALTHCARE, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OMC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-643-2415
Mailing Address - Street 1:17316 NE SR 65
Mailing Address - Street 2:
Mailing Address - City:HOSFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32334-9710
Mailing Address - Country:US
Mailing Address - Phone:850-379-8372
Mailing Address - Fax:850-379-8677
Practice Address - Street 1:17316 NE SR 65
Practice Address - Street 2:
Practice Address - City:HOSFORD
Practice Address - State:FL
Practice Address - Zip Code:32334-9998
Practice Address - Country:US
Practice Address - Phone:850-379-8372
Practice Address - Fax:850-379-8677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL027979800Medicaid