Healthcare Provider Details

I. General information

NPI: 1235812876
Provider Name (Legal Business Name): COASTAL WALK IN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 SOUTH DUPONT HIGHWAY ST 1
DOVER DE
19901
US

IV. Provider business mailing address

4601 SOUTH DUPONT HIGHWAY ST 1
DOVER DE
19901
US

V. Phone/Fax

Practice location:
  • Phone: 302-698-1100
  • Fax:
Mailing address:
  • Phone: 302-331-9026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RONNIE DIEM
Title or Position: OWNER
Credential: PA-C
Phone: 302-331-9026