Provider Demographics
NPI:1962911651
Name:EMERALD COAST MEMORY CLINIC, LLC
Entity type:Organization
Organization Name:EMERALD COAST MEMORY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:DR
Authorized Official - First Name:FARID
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEKAOUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-737-1816
Mailing Address - Street 1:755 GRAND BLVD STE 105B278
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-1838
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:755 GRAND BLVD STE 105B278
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-1838
Practice Address - Country:US
Practice Address - Phone:850-737-1816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME868722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty