| Entity Name: | OKALOOSA COUNTY COUNCIL ON AGING, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Non-Profit |
| Status: | Active |
| Date Filed: | 29 Jan 1971 (54 years ago) |
| Document Number: | 720154 |
| FEI/EIN Number | 591356076 |
| Address: | 207 HOSPITAL DRIVE, NORTHEAST, FT. WALTON BCH., FL, 32548, US |
| Mail Address: | 207 HOSPITAL DRIVE, NORTHEAST, FT. WALTON BCH., FL, 32548, US |
| ZIP code: | 32548 |
| County: | Okaloosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1861839086 | 2013-05-29 | 2022-09-01 | 207 HOSPITAL DR NE, FORT WALTON BEACH, FL, 325485066, US | 207 HOSPITAL DR NE, FORT WALTON BEACH, FL, 325485066, US | |||||||||||||||||||||||||||||
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| Phone | +1 850-833-9165 |
| Fax | 8508339389 |
Authorized person
| Name | MRS. KIMBERLY A. FRALEY |
| Role | EXECUTIVE DIRECTOR |
| Phone | 8508339165 |
Taxonomy
| Taxonomy Code | 251B00000X - Case Management Agency |
| Is Primary | No |
| Taxonomy Code | 251E00000X - Home Health Agency |
| License Number | 299992431 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 024863101 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| FRALEY KIMBERLY AED | Agent | 207 HOSPITAL DRIVE, FT WALTON BEACH, FL, 32548 |
| Name | Role | Address |
|---|---|---|
| FRALEY KIMBERLY A | Director | 405 Anchors Street, Niceville, FL, 32578 |
| Name | Role | Address |
|---|---|---|
| Blackwell Mary | Vice President | 1562 Glenlake Circle, Niceville, FL, 32578 |
| Name | Role | Address |
|---|---|---|
| MUNTZNER GREG | President | 23 Southwind Court, NICEVILLE, FL, 32578 |
| Name | Role | Address |
|---|---|---|
| RILEY-BRAODNAX DEBRA | Secretary | 207 Combs Manor Court, Fort Walton Beach, FL, 32548 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G05230900100 | ELDER HOME CARE | ACTIVE | 2005-08-18 | 2025-12-31 | No data | 207 HOSPITAL DRIVE, NE, FORT WALTON BEACH, FL, 32548 |
| G96057000175 | ELDER SERVICES OF OKALOOSA COUNTY | ACTIVE | 1996-02-26 | 2026-12-31 | No data | 207 HOSPITAL DRIVE NE, FT WALTON BEACH, FL, 32548 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
