Healthcare Provider Details

I. General information

NPI: 1821805995
Provider Name (Legal Business Name): COASTAL RENAL PARTNERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 N HIGHWAY 190
COVINGTON LA
70433-5364
US

IV. Provider business mailing address

PO BOX 3370
COVINGTON LA
70434-3370
US

V. Phone/Fax

Practice location:
  • Phone: 985-867-8585
  • Fax: 985-867-3644
Mailing address:
  • Phone: 985-867-8585
  • Fax: 985-867-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRANDI WILLIS
Title or Position: CREDENTIALING
Credential:
Phone: 985-256-5599