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General NPI Number Information
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NPI Number | 1639705387
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Entity Type | Organization
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Legal Business Name | COASTAL REGENEX LTD
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Dates
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Enumeration Date | 03/13/2020
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Last Update Date | 03/13/2020
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Provider Practice Location Address
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Address Line | 1013 EDEN WAY N STE B
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City | CHESAPEAKE
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State | VA
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Zip | 23320-2792
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Country | US
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Telephone | 757-297-6750
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Fax | 757-609-3473
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Provider Business Mailing Address
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Address Line | 182 ODD RD
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City | POQUOSON
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State | VA
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Zip | 23662-2035
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Country | US
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Telephone | 757-297-6750
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Fax | 757-609-3473
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Authorized Official
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Title or Position | OWNER
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Name | TREY WILLIAMS
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Credential | DO
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Telephone | 757-297-6750
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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