Healthcare Provider Details

I. General information

NPI: 1770576167
Provider Name (Legal Business Name): COASTLINE IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2290 W EAU GALLIE BLVD STE 104
MELBOURNE FL
32935-3134
US

IV. Provider business mailing address

2290 W EAU GALLIE BLVD STE 104
MELBOURNE FL
32935-3133
US

V. Phone/Fax

Practice location:
  • Phone: 321-253-2700
  • Fax: 321-253-2267
Mailing address:
  • Phone: 321-253-2700
  • Fax: 321-253-2267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberHCC3989
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberHCC3989
License Number StateFL

VIII. Authorized Official

Name: LAURA KASSA
Title or Position: COMPLIANCE OFFICER
Credential:
Phone: 904-640-9129