=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588101505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL MOBILITY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2017
-----------------------------------------------------
Last Update Date | 01/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5758 CUTTER LOOP
-----------------------------------------------------
City | DISCOVERY BAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94505-9505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-308-3101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5758 CUTTER LOOP
-----------------------------------------------------
City | DISCOVERY BAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94505-9505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-308-3101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BRYAN STEVEN GLESSNER
-----------------------------------------------------
Credential | ATP
-----------------------------------------------------
Telephone | 925-308-3101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------