Provider Demographics
NPI:1215973870
Name:FLORIDA DEPARTMENT OF HEALTH
Entity type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, MPH
Authorized Official - Phone:386-362-2708
Mailing Address - Street 1:PO DRAWER 6030
Mailing Address - Street 2:915 NOBLES FERRY ROAD
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-2800
Mailing Address - Country:US
Mailing Address - Phone:386-362-2708
Mailing Address - Fax:386-362-6301
Practice Address - Street 1:915 NOBLES FERRY RD
Practice Address - Street 2:PO DRAWER 6030
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-2800
Practice Address - Country:US
Practice Address - Phone:386-362-2708
Practice Address - Fax:386-362-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1223D0001X, 124Q00000X, 126800000X, 251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251K00000XAgenciesPublic Health or Welfare
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051832809Medicaid
FL051832800Medicaid
FL051832830Medicaid
FL051832809Medicaid