Basic Information
| Provider Information | |||||||||
| NPI: | 1689052359 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL VEIN & VASCULAR INSTITUTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3599 UNIVERSITY BLVD S | ||||||||
| Address2: | BLDG 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043995550 | ||||||||
| FaxNumber: | 9043464334 | ||||||||
| Practice Location | |||||||||
| Address1: | 7741 POINT MEADOWS DR | ||||||||
| Address2: | UNIT 104-106 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322569182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043995550 | ||||||||
| FaxNumber: | 9043464334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2015 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | MORI | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9043995550 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DRS. MORI, BEAN & BROOKS, PA | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.