MEDICARE: COASTAL QUALITY ASSISTED LIVING, 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1215765615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL QUALITY ASSISTED LIVING, LLC

Provider Business Mailing Address
First Line	:	804 ANITA ST
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-4006
Country	:	US
Telephone Number	:	772-242-1037
Fax Number	:	772-828-3514

Provider Business Practice Location Address
First Line	:	804 ANITA ST
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-4006
Country	:	US
Telephone Number	:	772-242-1037
Fax Number	:	772-828-3514

Authorized Official
Title or Position	:	ADMINISTRATOR/OWNER
Name	:	LORETTA SMITH
Credential	:
Telephone Number	:	772-242-1037

Provider Enumeration Date	:	07/25/2024
Last Update Date	:	07/25/2024

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