MEDICARE: COASTAL ER VII, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0002X	Emergency Care Clinic/Center	160288	TX

General Provider Information

NPI Number	:	1043762578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL ER VII, LLC

Provider Business Mailing Address
First Line	:	PO BOX 6327
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78466-6327
Country	:	US
Telephone Number	:	361-884-2904
Fax Number	:	361-884-1912

Provider Business Practice Location Address
First Line	:	3154 SE MILITARY DR STE 103
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223-3975
Country	:	US
Telephone Number	:	210-337-0911
Fax Number	:	361-884-1912

Authorized Official
Title or Position	:	LLC BOARD MEMBER
Name	:	DR. PAUL DAVID KENYON
Credential	:	MD
Telephone Number	:	210-337-0911

Provider Enumeration Date	:	11/01/2016
Last Update Date	:	11/01/2016

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