Healthcare Provider Details

I. General information

NPI: 1902970684
Provider Name (Legal Business Name): COASTAL CARE MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11761 BEACH BLVD SUITE 8
JACKSONVILLE FL
32246-6615
US

IV. Provider business mailing address

11761 BEACH BLVD SUITE 8
JACKSONVILLE FL
32246-6615
US

V. Phone/Fax

Practice location:
  • Phone: 904-642-3304
  • Fax: 904-928-3561
Mailing address:
  • Phone: 904-642-3304
  • Fax: 904-928-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CLINT D MILLER
Title or Position: PRESIDENT
Credential: DC
Phone: 904-642-3304