Healthcare Provider Details

I. General information

NPI: 1043172893
Provider Name (Legal Business Name): COASTAL MEDICAL MASSAGE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5599 STEWART ST
MILTON FL
32570-4344
US

IV. Provider business mailing address

3702 ROCKWOOD DR
PACE FL
32571-1867
US

V. Phone/Fax

Practice location:
  • Phone: 850-530-8082
  • Fax: 448-216-2818
Mailing address:
  • Phone: 850-530-8082
  • Fax: 448-216-2818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PAUL J PHELPS
Title or Position: BUSINESS MANAGER
Credential:
Phone: 850-530-8082