Healthcare Provider Details

I. General information

NPI: 1013664390
Provider Name (Legal Business Name): COASTAL PULMONARY AND SLEEP CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 6TH AVE
INDIALANTIC FL
32903-3204
US

IV. Provider business mailing address

140 6TH AVE
INDIALANTIC FL
32903-3204
US

V. Phone/Fax

Practice location:
  • Phone: 321-312-3501
  • Fax:
Mailing address:
  • Phone: 321-312-3501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: PRAKASH V REDDY
Title or Position: PHYSICIAN
Credential: MD
Phone: 321-312-3501