=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710118088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTLINE MEDICAL WALK IN CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2009
-----------------------------------------------------
Last Update Date | 11/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 FEDERAL ST SUITE 5
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19968-1157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-329-9046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 FEDERAL ST SUITE 5
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19968-1157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-329-9046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. AARON RAYMOND BLOCK
-----------------------------------------------------
Credential | PHYSICIAN ASSISTANT
-----------------------------------------------------
Telephone | 302-329-9046
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------