{
"Npi": {
"NPI": "1770576167",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "COASTLINE IMAGING LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2290 W EAU GALLIE BLVD",
"SecondLineMailingAddress": "STE 104",
"MailingAddressCityName": "MELBOURNE",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32935-3133",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "321-253-2700",
"MailingAddressFaxNumber": "321-253-2267",
"FirstLinePracticeLocationAddress": "2290 W EAU GALLIE BLVD STE 104",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MELBOURNE",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "32935-3134",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "321-253-2700",
"PracticeLocationAddressFaxNumber": "321-253-2267",
"EnumerationDate": "08/31/2005",
"LastUpdateDate": "07/11/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KASSA",
"AuthorizedOfficialFirstName": "LAURA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "COMPLIANCE OFFICER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "904-640-9129",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "2085U0001X",
"TaxonomyName": "Diagnostic Ultrasound Physician",
"LicenseNumber": "HCC3989",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "2085R0202X",
"TaxonomyName": "Diagnostic Radiology Physician",
"LicenseNumber": "HCC3989",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}