Provider Demographics
NPI:1093384489
Name:EMERALD COAST HEALTHCARE, LLC
Entity Type:Organization
Organization Name:EMERALD COAST HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:CORTLAND
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-397-0658
Mailing Address - Street 1:27702 CROWN VALLEY PKWY STE D4
Mailing Address - Street 2:BOX 151
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0613
Mailing Address - Country:US
Mailing Address - Phone:949-397-0658
Mailing Address - Fax:
Practice Address - Street 1:3495 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-3519
Practice Address - Country:US
Practice Address - Phone:949-397-0658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility