Provider Demographics
NPI:1356104269
Name:TMS OF EMERALD COAST LLC
Entity type:Organization
Organization Name:TMS OF EMERALD COAST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-245-0577
Mailing Address - Street 1:403 HOLLYWOOD BLVD NW STE 103A
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4531
Mailing Address - Country:US
Mailing Address - Phone:801-245-0577
Mailing Address - Fax:
Practice Address - Street 1:403 HOLLYWOOD BLVD NW STE 103A
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4531
Practice Address - Country:US
Practice Address - Phone:801-245-0577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-02
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health