=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013284603
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL AMBULANCE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2011
-----------------------------------------------------
Last Update Date | 08/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 ROBERTSON BLVD STE B
-----------------------------------------------------
City | WALTERBORO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29488-5713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-935-5525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 478 CESSNA AVE
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29407-2245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-695-8420
-----------------------------------------------------
Fax | 864-643-2485
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. VLASTIMIL SMETKA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 888-935-5525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 295
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------