MEDICARE: COASTAL CONCIERGE SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	L16000112704	OTHER	FL	DOCUMENT NUMBER

General Provider Information

NPI Number	:	1144671553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CONCIERGE SERVICES LLC

Provider Business Mailing Address
First Line	:	2690 SE WILLOUGHBY BLVD
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34994-4700
Country	:	US
Telephone Number	:	772-485-8931
Fax Number	:

Provider Business Practice Location Address
First Line	:	2690 SE WILLOUGHBY BLVD
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34994-4700
Country	:	US
Telephone Number	:	772-485-8931
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. MARK ECKSTROM
Credential	:
Telephone Number	:	772-485-8931

Provider Enumeration Date	:	06/27/2016
Last Update Date	:	06/27/2016

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