Healthcare Provider Details

I. General information

NPI: 1205078060
Provider Name (Legal Business Name): COASTAL ORTHOPEDIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 03/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 NW PARK ST
OKEECHOBEE FL
34972-4155
US

IV. Provider business mailing address

510 SW PORT ST LUCIE BLVD
PORT ST LUCIE FL
34953-1943
US

V. Phone/Fax

Practice location:
  • Phone: 863-763-0079
  • Fax: 772-336-4040
Mailing address:
  • Phone: 772-871-9200
  • Fax: 772-336-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPRO 84
License Number StateFL

VIII. Authorized Official

Name: JOSEPH PERRETTA
Title or Position: OWNER
Credential: CP
Phone: 772-871-9200