Provider Demographics
NPI:1730496126
Name:TRANQUIL SHORES LLC
Entity Type:Organization
Organization Name:TRANQUIL SHORES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-391-7001
Mailing Address - Street 1:4300 DUHME RD FL 2
Mailing Address - Street 2:
Mailing Address - City:MADEIRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33708-2876
Mailing Address - Country:US
Mailing Address - Phone:727-391-7001
Mailing Address - Fax:727-391-3125
Practice Address - Street 1:4300 DUHME RD FL 2
Practice Address - Street 2:
Practice Address - City:MADEIRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33708-2876
Practice Address - Country:US
Practice Address - Phone:727-391-7001
Practice Address - Fax:727-391-3125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-07
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL06-52-AD-495901101YA0400X, 101YM0800X, 261QM0801X, 261QM0850X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty