Provider Demographics
NPI:1417287855
Name:EMERALD COAST WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:EMERALD COAST WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BOILINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-543-5678
Mailing Address - Street 1:138 BAYWIND DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4800
Mailing Address - Country:US
Mailing Address - Phone:850-398-4155
Mailing Address - Fax:850-398-4142
Practice Address - Street 1:138 BAYWIND DR
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-4800
Practice Address - Country:US
Practice Address - Phone:850-398-4155
Practice Address - Fax:850-398-4142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008056800Medicaid
FL008056800Medicaid