Healthcare Provider Details

I. General information

NPI: 1902176563
Provider Name (Legal Business Name): COASTLINE MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 VIKING DR STE E
VIRGINIA BEACH VA
23452-7323
US

IV. Provider business mailing address

509 VIKING DR STE E
VIRGINIA BEACH VA
23452-7323
US

V. Phone/Fax

Practice location:
  • Phone: 757-275-8050
  • Fax: 888-600-5328
Mailing address:
  • Phone: 757-275-8050
  • Fax: 888-600-5328

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: JAMES MICHAEL RAY
Title or Position: PRESIDENT
Credential: CFO
Phone: 757-275-8050