=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598130098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL DETOX, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2015
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1131 SE INDIAN ST
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34997-5688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-612-0130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3007 SW MARTIN DOWNS BLVD
-----------------------------------------------------
City | PALM CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34990-2644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | CHRISTINA TUCKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-219-1355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Health Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 284300000X
-----------------------------------------------------
Taxonomy Name | Special Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------