Healthcare Provider Details

I. General information

NPI: 1316225568
Provider Name (Legal Business Name): COASTAL FOOT CLINIC, A P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 ROBERTS DR SUITE G
NEW ROADS LA
70760-2661
US

IV. Provider business mailing address

PO BOX 575
LIVONIA LA
70755-0575
US

V. Phone/Fax

Practice location:
  • Phone: 225-638-6640
  • Fax: 225-618-0863
Mailing address:
  • Phone: 225-234-0048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPD165R
License Number StateLA

VIII. Authorized Official

Name: DR. RICHARD G PALECKI
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 225-718-5314