Provider Demographics
NPI:1063521698
Name:EMERALD COAST AUDIOLOGY PA
Entity type:Organization
Organization Name:EMERALD COAST AUDIOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARVER
Authorized Official - Middle Name:GRAY
Authorized Official - Last Name:DETHLOFF
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:850-315-4141
Mailing Address - Street 1:11 RACETRACK RD NE STE E4
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1867
Mailing Address - Country:US
Mailing Address - Phone:850-315-4141
Mailing Address - Fax:850-226-8242
Practice Address - Street 1:11 RACETRACK RD NE STE E4
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1867
Practice Address - Country:US
Practice Address - Phone:850-315-4141
Practice Address - Fax:850-226-8242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1018231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL600389300Medicaid
FLS9298OtherBCBS
FLAD335Medicare PIN