Healthcare Provider Details

I. General information

NPI: 1164990040
Provider Name (Legal Business Name): COASTAL PROSTHETICS AND ORTHOTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 NETWORK STA
CHESAPEAKE VA
23320-3851
US

IV. Provider business mailing address

433 NETWORK STA
CHESAPEAKE VA
23320-3851
US

V. Phone/Fax

Practice location:
  • Phone: 757-892-5300
  • Fax: 757-892-5303
Mailing address:
  • Phone: 757-892-5300
  • Fax: 757-892-5303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: KAREN VAUGHN
Title or Position: ADMINISTRATOR
Credential:
Phone: 757-828-5112