Provider Demographics
NPI:1255827226
Name:NATURE COAST MIND BODY MEDICINE, LLC
Entity Type:Organization
Organization Name:NATURE COAST MIND BODY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:DR
Authorized Official - First Name:EILIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-631-7460
Mailing Address - Street 1:210 S SALISBURY TER
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-5104
Mailing Address - Country:US
Mailing Address - Phone:352-631-7460
Mailing Address - Fax:
Practice Address - Street 1:210 S SALISBURY TER
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-5104
Practice Address - Country:US
Practice Address - Phone:352-631-7460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty