Healthcare Provider Details

I. General information

NPI: 1285554436
Provider Name (Legal Business Name): COASTAL SPA AND SALON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RACETRACK RD NW
FORT WALTON BEACH FL
32547-1642
US

IV. Provider business mailing address

20 RACETRACK RD NW
FORT WALTON BEACH FL
32547-1642
US

V. Phone/Fax

Practice location:
  • Phone: 850-240-5353
  • Fax:
Mailing address:
  • Phone: 850-240-5353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: NATTIDA BUKTHAN
Title or Position: OWNER
Credential: LE
Phone: 850-240-5353