Healthcare Provider Details

I. General information

NPI: 1598130098
Provider Name (Legal Business Name): COASTAL DETOX, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 10/01/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 SE INDIAN ST
STUART FL
34997-5688
US

IV. Provider business mailing address

3007 SW MARTIN DOWNS BLVD
PALM CITY FL
34990-2644
US

V. Phone/Fax

Practice location:
  • Phone: 772-612-0130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code284300000X
TaxonomySpecial Hospital
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA TUCKER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 772-219-1355