=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376228726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL VIEW COMMUNITY CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2023
-----------------------------------------------------
Last Update Date | 03/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1725 W DR MARTIN LUTHER KING JR BLVD STE 100
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33607-6507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-793-8731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1725 W DR MARTIN LUTHER KING JR BLVD STE 100
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33607-6507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FIDEL GONZALEZ DIAZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-770-3816
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------