Provider Demographics
NPI:1053606988
Name:HEALTHSTAT PENSACOLA LLC
Entity type:Organization
Organization Name:HEALTHSTAT PENSACOLA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP SALES & MARKETING
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KINZLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-529-6161
Mailing Address - Street 1:4601 CHARLOTTE PARK DR
Mailing Address - Street 2:SUITE 390
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1915
Mailing Address - Country:US
Mailing Address - Phone:704-529-6161
Mailing Address - Fax:704-936-5570
Practice Address - Street 1:1678 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8618
Practice Address - Country:US
Practice Address - Phone:850-479-3790
Practice Address - Fax:850-479-3920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5706657OtherNCPDP PROVIDER IDENTIFICATION NUMBER