Healthcare Provider Details

I. General information

NPI: 1285881946
Provider Name (Legal Business Name): PALM COAST CARDIOVASCULAR INSTITUTE PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 OLD KINGS RD N STE C101
PALM COAST FL
32137-8261
US

IV. Provider business mailing address

19 OLD KINGS RD N STE C101
PALM COAST FL
32137-8261
US

V. Phone/Fax

Practice location:
  • Phone: 386-446-6540
  • Fax:
Mailing address:
  • Phone: 386-446-6540
  • Fax: 386-447-7148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME80454
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DOMENIC MARINI
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 386-586-4404