1700837572 NPI number — CARESERVICES OF THE EMERALD COAST

Table of content: (NPI 1700837572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700837572 NPI number — CARESERVICES OF THE EMERALD COAST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARESERVICES OF THE EMERALD COAST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700837572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 HIGHWAY 1187
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-6124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-469-6739
Provider Business Mailing Address Fax Number:
817-801-3486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
348 MIRACLE STRIP PKWY SW STE 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WALTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32548-5257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-862-5424
Provider Business Practice Location Address Fax Number:
850-862-5131
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EDDINS
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-469-6739

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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