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General NPI Number Information
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NPI Number | 1699067959
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Entity Type | Organization
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Legal Business Name | COASTAL PREVENTATIVE MEDICINE, LLC
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Dates
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Enumeration Date | 05/04/2011
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Last Update Date | 05/04/2011
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Provider Practice Location Address
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Address Line | 3300 LADNIER RD
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City | GAUTIER
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State | MS
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Zip | 39553-5909
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Country | US
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Telephone | 228-497-2652
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Fax | 228-497-3667
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Provider Business Mailing Address
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Address Line | PO BOX 17708
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City | HATTIESBURG
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State | MS
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Zip | 39404-7708
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Country | US
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Telephone | 601-296-2552
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Fax | 601-296-2397
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Authorized Official
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Title or Position | ADMIN
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Name | MR. BARRY MONDAY
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Credential |
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Telephone | 601-296-2552
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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