=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962911651
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERALD COAST MEMORY CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2017
-----------------------------------------------------
Last Update Date | 09/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 755 GRAND BLVD STE 105B278
-----------------------------------------------------
City | MIRAMAR BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32550-1838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-737-1816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 755 GRAND BLVD STE 105B278
-----------------------------------------------------
City | MIRAMAR BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32550-1838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGRM
-----------------------------------------------------
Name | DR. FARID CHEKAOUI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 850-737-1816
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME86872
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------