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General NPI Number Information
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NPI Number | 1972834760
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Entity Type | Organization
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Legal Business Name | COASTAL FOOT & ANKLE WELLNESS CENTER LLC
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Dates
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Enumeration Date | 01/19/2010
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Last Update Date | 12/27/2020
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Provider Practice Location Address
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Address Line | 1740 TREE BLVD STE 112
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City | ST AUGUSTINE
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State | FL
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Zip | 32084-5720
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Country | US
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Telephone | 904-826-1900
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Fax | 904-826-1920
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Provider Business Mailing Address
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Address Line | 1740 TREE BLVD STE 112
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City | ST AUGUSTINE
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State | FL
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Zip | 32084-5720
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Country | US
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Telephone | 904-826-1900
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Fax | 904-826-1920
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Authorized Official
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Title or Position | OWNER
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Name | DR. RICHARD W JOHNSON
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Credential | DPM
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Telephone | 904-826-1900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | P02829
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License Number State | FL
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