Healthcare Provider Details

I. General information

NPI: 1083442826
Provider Name (Legal Business Name): FIRST COAST MEDICAL & DENTAL SUPPLY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N ONE DR STE B
ST AUGUSTINE FL
32095-8372
US

IV. Provider business mailing address

140 N ONE DR STE B
ST AUGUSTINE FL
32095-8372
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-2549
  • Fax: 904-814-8380
Mailing address:
  • Phone: 904-460-2549
  • Fax: 904-814-8380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. LADD NICHOLS
Title or Position: MANAGER
Credential:
Phone: 904-881-1804