Healthcare Provider Details

I. General information

NPI: 1467780494
Provider Name (Legal Business Name): COASTAL SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1594 ROUTE 9 UNIT 6
TOMS RIVER NJ
08755-3280
US

IV. Provider business mailing address

1594 ROUTE 9 UNIT 6
TOMS RIVER NJ
08755-3280
US

V. Phone/Fax

Practice location:
  • Phone: 732-349-8888
  • Fax: 732-349-8880
Mailing address:
  • Phone: 732-349-8888
  • Fax: 732-349-8880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number25MA06570700
License Number StateNJ

VIII. Authorized Official

Name: DR. ANDREW LLOYD NELSON
Title or Position: OWNER
Credential: M.D.
Phone: 347-334-1733