Healthcare Provider Details

I. General information

NPI: 1760936900
Provider Name (Legal Business Name): COASTAL MOBILE PHLEBOTOMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 CHILDS ST
STONINGTON ME
04681-3514
US

IV. Provider business mailing address

45 CHILDS ST
STONINGTON ME
04681-3514
US

V. Phone/Fax

Practice location:
  • Phone: 207-542-9826
  • Fax: 207-942-5663
Mailing address:
  • Phone: 207-542-9826
  • Fax: 207-942-5663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number8765180
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number8765180
License Number StateME

VIII. Authorized Official

Name: YVONNE MARIE JONES
Title or Position: OWNER
Credential: CMA/CPT
Phone: 207-542-9826