MEDICARE: COASTAL PROSTHETICS AND ORTHOTICS, 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	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	39563	OTHER	VA	SENTARA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1029129	OTHER	VA	ACM
4	434534	OTHER	VA	BCBS

General Provider Information

NPI Number	:	1275178816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL PROSTHETICS AND ORTHOTICS, LLC

Provider Business Mailing Address
First Line	:	433 NETWORK STA
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-3851
Country	:	US
Telephone Number	:	757-892-5300
Fax Number	:

Provider Business Practice Location Address
First Line	:	1134 N ROAD ST
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-3322
Country	:	US
Telephone Number	:	757-892-5300
Fax Number	:	757-892-5303

Authorized Official
Title or Position	:	ADMINISTRATIVE EXECUTIVE
Name	:	BRITTANY SIVERD
Credential	:
Telephone Number	:	757-892-5300

Provider Enumeration Date	:	11/07/2019
Last Update Date	:	11/07/2019

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