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General NPI Number Information
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NPI Number | 1063521698
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Entity Type | Organization
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Legal Business Name | EMERALD COAST AUDIOLOGY PA
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 07/21/2020
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Provider Practice Location Address
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Address Line | 11 RACETRACK RD NE STE E4
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-1867
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Country | US
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Telephone | 850-315-4141
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Fax | 850-226-8242
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Provider Business Mailing Address
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Address Line | 11 RACETRACK RD NE STE E4
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-1867
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Country | US
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Telephone | 850-315-4141
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Fax | 850-226-8242
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Authorized Official
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Title or Position | OWNER
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Name | CARVER GRAY DETHLOFF
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Credential | AUD
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Telephone | 850-315-4141
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | AY1018
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License Number State | FL
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