| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 1011 E Main St, Haines, Florida |
| Authorized Official Name and Position | Clayton Dale Reedy (OWNER/PROVIDER) |
| Authorized Official Contact | 8634194422 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1011 E Main St Haines FL 33844 Ph: (863) 419-4422 | 1011 E Main St Haines FL 33844 Ph: (863) 419-4422 |
| NPI Number | 1144907429 |
|---|---|
| Provider Enumeration Date | 06/29/2023 |
| Last Update Date | 01/23/2025 |
| Medicare PECOS PAC ID | 5799149860 |
|---|---|
| Medicare Enrollment ID | O20230908001054 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1144907429 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| 363LA2200X | Nurse Practitioner - Adult Health | (* (Not Available)) | Secondary |
| Provider Name | Clayton Reedy |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1558765479 PECOS PAC ID: 7517281876 Enrollment ID: I20160808002794 |
| Provider Name | Jessica Crisostomo |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1578207916 PECOS PAC ID: 3476938994 Enrollment ID: I20220920002905 |