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General NPI Number Information
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NPI Number | 1629447511
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Entity Type | Organization
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Legal Business Name | COASTAL FOOT AND ANKLE SPECIALIST, LLC
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Dates
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Enumeration Date | 09/21/2015
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Last Update Date | 01/17/2017
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Provider Practice Location Address
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Address Line | 10 PROFESSIONAL DR
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City | BRUNSWICK
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State | GA
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Zip | 31520-3774
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Country | US
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Telephone | 912-265-0709
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Fax | 912-264-5712
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Provider Business Mailing Address
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Address Line | 10 PROFESSIONAL DR
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City | BRUNSWICK
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State | GA
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Zip | 31520-3774
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Country | US
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Telephone | 912-265-0709
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Fax | 912-264-5712
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. NICHOLE DANIELLE MANNING
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Credential |
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Telephone | 912-265-0709
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | POD000997
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License Number State | GA
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