Healthcare Provider Details

I. General information

NPI: 1720483043
Provider Name (Legal Business Name): COASTAL COMPLETE CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PLANTATION RD
PERRY FL
32348-6000
US

IV. Provider business mailing address

100 PLANTATION RD
PERRY FL
32348-6000
US

V. Phone/Fax

Practice location:
  • Phone: 850-584-6000
  • Fax:
Mailing address:
  • Phone: 850-584-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JAMIE PORTWOOD
Title or Position: BILLING MANAGER
Credential:
Phone: 850-584-6000