Basic Information
| Provider Information | |||||||||
| NPI: | 1720128499 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL MEDICAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COASTAL MEDICAL - WAKEFIELD MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5626 OBERLIN DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586252990 | ||||||||
| FaxNumber: | 8586252999 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 KENYON AVE | ||||||||
| Address2: | SUITE 321 | ||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028794239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017830084 | ||||||||
| FaxNumber: | 4017820005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | HEINE | ||||||||
| AuthorizedOfficialFirstName: | KENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8586252990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDVANTX,INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | MD06582 | RI | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.