Provider Demographics
NPI:1942580873
Name:EMERALD COAST LIFECARE, INC.
Entity Type:Organization
Organization Name:EMERALD COAST LIFECARE, INC.
Other - Org Name:BRIGHTSTAR EMERALD COAST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:RUCKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-659-3125
Mailing Address - Street 1:815 BAYSHORE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2548
Mailing Address - Country:US
Mailing Address - Phone:850-659-3125
Mailing Address - Fax:850-659-3123
Practice Address - Street 1:815 BAYSHORE DR
Practice Address - Street 2:SUITE A
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2548
Practice Address - Country:US
Practice Address - Phone:850-659-3125
Practice Address - Fax:850-659-3123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL39967218251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health