=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093384489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERALD COAST HEALTHCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2021
-----------------------------------------------------
Last Update Date | 06/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3495 JEFFERSON ST
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92504-3519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-397-0658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27702 CROWN VALLEY PKWY STE D4 BOX 151
-----------------------------------------------------
City | LADERA RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694-0613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-397-0658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ADAM CORTLAND GREEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-397-0658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------