Provider Demographics
NPI:1831523612
Name:OUR LADY OF ANGELS, ST. JOSEPH MEDICAL CLINIC, INC
Entity type:Organization
Organization Name:OUR LADY OF ANGELS, ST. JOSEPH MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CONKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-434-8162
Mailing Address - Street 1:131 W. INTENDENCIA ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502
Mailing Address - Country:US
Mailing Address - Phone:850-434-8162
Mailing Address - Fax:850-434-8996
Practice Address - Street 1:131 W. INTENDENCIA ST.
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502
Practice Address - Country:US
Practice Address - Phone:850-434-8162
Practice Address - Fax:850-434-8996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-28
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care