=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609616291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL TIDES SURGICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2024
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1002 N ARNOLD ROAD SUITE 401
-----------------------------------------------------
City | PANAMA CITY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-509-7567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1002 N ARNOLD ROAD SUITE 401
-----------------------------------------------------
City | PANAMA CITY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DANIEL DAVID STANNARD
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 850-509-7567
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------