Healthcare Provider Details

I. General information

NPI: 1518647817
Provider Name (Legal Business Name): COASTAL DYSPHAGIA SOLUTIONS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 SW 15TH ST
CAPE CORAL FL
33991-2736
US

IV. Provider business mailing address

1242 SW PINE ISLAND RD STE 42 #441
CAPE CORAL FL
33991
US

V. Phone/Fax

Practice location:
  • Phone: 239-763-0353
  • Fax:
Mailing address:
  • Phone: 239-763-0353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. VANESSA MARTINEZ
Title or Position: SPEECH-LANGUAGE PATHOLOGIST/OWNER
Credential: MS, CCC-SLP
Phone: 239-763-0353