Healthcare Provider Details

I. General information

NPI: 1275052755
Provider Name (Legal Business Name): COASTAL FOOT & ANKLE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 AQUIDNECK AVE
MIDDLETOWN RI
02842-7280
US

IV. Provider business mailing address

850 AQUIDNECK AVE
MIDDLETOWN RI
02842-7280
US

V. Phone/Fax

Practice location:
  • Phone: 401-849-2157
  • Fax: 401-848-8441
Mailing address:
  • Phone: 401-849-2157
  • Fax: 401-848-8441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDPM00316
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number2210
License Number StateMA

VIII. Authorized Official

Name: JONATHAN SABOURIN
Title or Position: OWNER
Credential: DPM
Phone: 508-258-1717