=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568510618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL CARE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 10/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3066 SW MARTIN DOWNS BLVD UNIT 6 STE B
-----------------------------------------------------
City | PALM CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34990-2683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-781-2781
-----------------------------------------------------
Fax | 772-781-2782
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 417
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34995-0417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-223-2832
-----------------------------------------------------
Fax | 772-223-5646
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT LESTER LORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-223-5945
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 1998122013
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | 1998122013
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------