| Entity Name: | THE EMERALD COAST NECK & BACK CLINIC, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 10 Mar 1999 (26 years ago) |
| Document Number: | P99000023752 |
| FEI/EIN Number | 593562781 |
| Address: | 1003 College Blvd. W, Suite 4, Niceville, FL, 32578, US |
| Mail Address: | 1003 College Blvd. W, Suite 4, Niceville, FL, 32578, US |
| ZIP code: | 32578 |
| County: | Okaloosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1386916237 | 2012-02-07 | 2022-12-29 | 1003 COLLEGE BLVD W, SUITE 4, NICEVILLE, FL, 325781068, US | 1003 COLLEGE BLVD W, SUITE 4, NICEVILLE, FL, 325781068, US | |||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 850-279-6485 |
| Fax | 8502796546 |
Authorized person
| Name | CHRISTO W. KOULISIS |
| Role | PRESIDENT |
| Phone | 8502796485 |
Taxonomy
| Taxonomy Code | 207X00000X - Orthopaedic Surgery Physician |
| License Number | ME0053933 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 207XS0117X - Orthopaedic Surgery of the Spine Physician |
| License Number | ME0053933 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | DEPARTMENT OF LABOR |
| Number | 162510700 |
| State | FL |
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 07915 |
| State | FL |
| Issuer | MEDICAID |
| Number | 256355000 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| Koulisis Christo WDr. | Agent | 1003 College Blvd. W, Niceville, FL, 32578 |
| Name | Role | Address |
|---|---|---|
| KOULISIS CHRISTO W | Director | 1003 College Blvd. W, Niceville, FL, 32578 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT NAME CHANGED | 2019-04-08 | Koulisis, Christo W, Dr. | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2016-04-12 | 1003 College Blvd. W, Suite 4, Niceville, FL 32578 | No data |
| CHANGE OF MAILING ADDRESS | 2013-04-23 | 1003 College Blvd. W, Suite 4, Niceville, FL 32578 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2013-04-23 | 1003 College Blvd. W, Suite 4, Niceville, FL 32578 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-02 |
| ANNUAL REPORT | 2023-04-25 |
| ANNUAL REPORT | 2022-04-21 |
| ANNUAL REPORT | 2021-04-23 |
| ANNUAL REPORT | 2020-04-30 |
| ANNUAL REPORT | 2019-04-08 |
| ANNUAL REPORT | 2018-04-12 |
| ANNUAL REPORT | 2017-04-14 |
| ANNUAL REPORT | 2016-04-12 |
| ANNUAL REPORT | 2015-04-13 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
