Healthcare Provider Details

I. General information

NPI: 1114119393
Provider Name (Legal Business Name): COASTAL AESTHETIC CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HEALTH PARK BLVD STE 109
SAINT AUGUSTINE FL
32086-5794
US

IV. Provider business mailing address

PO BOX 3123
SAINT AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 904-245-1320
  • Fax: 866-878-2261
Mailing address:
  • Phone: 904-245-1320
  • Fax: 866-878-2261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME99062
License Number StateFL

VIII. Authorized Official

Name: ANH VU
Title or Position: OWNER
Credential: MD
Phone: 904-245-1320