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General NPI Number Information
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NPI Number | 1275799322
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Entity Type | Organization
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Legal Business Name | COSTER CARE
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Dates
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Enumeration Date | 07/29/2008
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Last Update Date | 10/06/2008
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Provider Practice Location Address
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Address Line | 91 SAMMY MCGHEE BLVD SUITE 101
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City | JASPER
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State | GA
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Zip | 30143-7703
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Country | US
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Telephone | 706-253-6200
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Fax | 706-253-6276
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Provider Business Mailing Address
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Address Line | 91 SAMMY MCGHEE BLVD SUITE 101
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City | JASPER
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State | GA
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Zip | 30143-7703
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Country | US
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Telephone | 706-253-6200
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Fax | 706-253-6276
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. CHARLES LEO COSTER
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Credential | DO
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Telephone | 706-253-6200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 045754
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License Number State | GA
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