| Entity Name: | DESTIN SURGERY CLINIC, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 15 Sep 1993 (31 years ago) |
| Document Number: | P93000065450 |
| FEI/EIN Number | 593203584 |
| Address: | 415 MOUNTAIN DRIVE, STE. 6, DESTIN, FL, 32541, US |
| Mail Address: | P. O. BOX 368, DESTIN, FL, 32540, US |
| ZIP code: | 32541 |
| County: | Okaloosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1457661605 | 2010-10-20 | 2010-10-20 | P.O. BOX 368, DESTIN, FL, 32540, US | 415 MOUNTAIN DRIVE, SUITE # 6, DESTIN, FL, 32541, US | |||||||||||||||||||
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| Phone | +1 850-837-8831 |
| Fax | 8508379137 |
Authorized person
| Name | JAMES A MOODY |
| Role | PHYSICIAN/OWNER |
| Phone | 8508378831 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | ME0052108 |
| State | FL |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| MATTHEWS DANA | Agent | 4475 LEGENDARY DRIVE, DESTIN, FL, 32541 |
| Name | Role | Address |
|---|---|---|
| MOODY JAMES A | Director | 415 MOUNTAIN DR, STE 6, DESTIN, FL, 43541 |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
