Healthcare Provider Details

I. General information

NPI: 1396297743
Provider Name (Legal Business Name): COASTAL PHYSICIANS REGIONAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3154 SE MILITARY DR STE 103
SAN ANTONIO TX
78223-3975
US

IV. Provider business mailing address

PO BOX 6327
CORPUS CHRISTI TX
78466-6327
US

V. Phone/Fax

Practice location:
  • Phone: 210-337-0911
  • Fax:
Mailing address:
  • Phone: 210-337-0911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number160288
License Number StateTX

VIII. Authorized Official

Name: DR. PAUL DAVID KENYON
Title or Position: LLC BOARD MEMBER
Credential: MD
Phone: 210-337-0911