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General NPI Number Information
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NPI Number | 1487829842
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Entity Type | Organization
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Legal Business Name | COASTAL FOOT CLINIC INC
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Dates
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Enumeration Date | 04/28/2008
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Last Update Date | 05/29/2015
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Provider Practice Location Address
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Address Line | 230 ROBERTS DR SUITE G
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City | NEW ROADS
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State | LA
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Zip | 70760-2661
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Country | US
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Telephone | 225-638-6640
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Fax | 225-618-0863
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Provider Business Mailing Address
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Address Line | PO BOX 575
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City | LIVONIA
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State | LA
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Zip | 70755-0575
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Country | US
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Telephone | 225-718-5314
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Fax | 225-618-0863
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Authorized Official
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Title or Position | OWNER
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Name | RICHARD PALECKI
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Credential | DPM
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Telephone | 225-718-5314
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | PD165R
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License Number State | LA
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