=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396010120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COAST FAMILY CARE GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2012
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 451 SW BETHANY DR STE 103
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-1964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-867-8019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 451 SW BETHANY DR STE 103
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-1964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-867-8019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DENIS A VILCHEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 832-867-8019
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------