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General NPI Number Information
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NPI Number | 1891126652
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Entity Type | Organization
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Legal Business Name | COASTAL LIFE AMBULANCE, INC.
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Dates
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Enumeration Date | 12/04/2013
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Last Update Date | 05/04/2014
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Provider Practice Location Address
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Address Line | 415 ROBERTSON BLVD STE B
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City | WALTERBORO
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State | SC
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Zip | 29488-5713
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Country | US
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Telephone | 888-935-5525
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 487
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City | WALTERBORO
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State | SC
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Zip | 29488-0005
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Country | US
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Telephone | 888-935-5525
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JAMES CLAIR BRUSSEAU II
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Credential |
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Telephone | 916-871-8487
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3416L0300X
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Taxonomy Name | Land Ambulance
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License Number |
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License Number State |
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