Healthcare Provider Details

I. General information

NPI: 1568510618
Provider Name (Legal Business Name): COASTAL CARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3066 SW MARTIN DOWNS BLVD UNIT 6 STE B
PALM CITY FL
34990-2683
US

IV. Provider business mailing address

PO BOX 417
STUART FL
34995-0417
US

V. Phone/Fax

Practice location:
  • Phone: 772-781-2781
  • Fax: 772-781-2782
Mailing address:
  • Phone: 772-223-2832
  • Fax: 772-223-5646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number1998122013
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1998122013
License Number StateFL

VIII. Authorized Official

Name: ROBERT LESTER LORD
Title or Position: PRESIDENT
Credential:
Phone: 772-223-5945