Provider Demographics
NPI:1386611085
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:MR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-362-2708
Mailing Address - Street 1:PO BOX 6030
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-6030
Mailing Address - Country:US
Mailing Address - Phone:386-362-2708
Mailing Address - Fax:386-362-6301
Practice Address - Street 1:140 SW VIRGINIA CIR
Practice Address - Street 2:
Practice Address - City:MAYO
Practice Address - State:FL
Practice Address - Zip Code:32066-4064
Practice Address - Country:US
Practice Address - Phone:386-294-1321
Practice Address - Fax:386-294-3876
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FL DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-02
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029034300Medicaid
FL029034300Medicaid