Healthcare Provider Details

I. General information

NPI: 1316966336
Provider Name (Legal Business Name): COASTAL CARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 SE RIVERSIDE DR
STUART FL
34994-2579
US

IV. Provider business mailing address

PO BOX 9033
STUART FL
34995-9033
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-4903
  • Fax: 772-223-5622
Mailing address:
  • Phone: 772-223-4903
  • Fax: 772-223-5622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number904
License Number StateFL

VIII. Authorized Official

Name: MR. MARK R ROBITAILLE
Title or Position: PRESIDENT/CEO
Credential:
Phone: 772-223-4903