Healthcare Provider Details

I. General information

NPI: 1275552358
Provider Name (Legal Business Name): COASTAL FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 S RIDGEWOOD AVE
EDGEWATER FL
32132-2720
US

IV. Provider business mailing address

1404 S RIDGEWOOD AVE
EDGEWATER FL
32132-2720
US

V. Phone/Fax

Practice location:
  • Phone: 386-426-8166
  • Fax: 386-426-6399
Mailing address:
  • Phone: 386-426-8166
  • Fax: 386-426-6399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL800015935
License Number StateFL

VIII. Authorized Official

Name: PAM LACEY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 386-761-6044