Healthcare Provider Details

I. General information

NPI: 1699266361
Provider Name (Legal Business Name): COASTAL VISIONCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2186 HARRIS AVE NE STE 1
PALM BAY FL
32905
US

IV. Provider business mailing address

2186 HARRIS AVE NE STE 1
PALM BAY FL
32905-4044
US

V. Phone/Fax

Practice location:
  • Phone: 321-724-2020
  • Fax:
Mailing address:
  • Phone: 321-724-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN SORENSEN
Title or Position: OWNER
Credential: OD
Phone: 614-302-5395