Healthcare Provider Details

I. General information

NPI: 1255827226
Provider Name (Legal Business Name): NATURE COAST MIND BODY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 01/04/2020
Certification Date: 01/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S SALISBURY TER
LECANTO FL
34461-5104
US

IV. Provider business mailing address

210 S SALISBURY TER
LECANTO FL
34461-5104
US

V. Phone/Fax

Practice location:
  • Phone: 352-631-7460
  • Fax:
Mailing address:
  • Phone: 352-631-7460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. EILIS CLARK
Title or Position: MGRM
Credential: MD
Phone: 352-631-7460