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General NPI Number Information
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NPI Number | 1053583526
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Entity Type | Organization
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Legal Business Name | COASTAL IMAGING INC
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Dates
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Enumeration Date | 03/25/2008
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Last Update Date | 03/25/2008
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Provider Practice Location Address
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Address Line | 20020 VETERANS BLVD
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City | PORT CHARLOTTE
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State | FL
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Zip | 33954-2112
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Country | US
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Telephone | 941-629-9877
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Fax | 941-766-0001
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Provider Business Mailing Address
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Address Line | 26092 OCELOT LN
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City | PUNTA GORDA
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State | FL
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Zip | 33983-6131
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Country | US
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Telephone | 941-629-9877
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Fax | 941-766-0001
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Authorized Official
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Title or Position | ULTRASOUND TECH
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Name | LISA BOUCHER
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Credential |
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Telephone | 941-421-2116
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number | 53741
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License Number State | MA
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