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NPI Code Detail

MEDICARE: COASTAL FAMILY PRACTICE LLC

MEDICARE: COASTAL FAMILY PRACTICE 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
1207Q00000XFamily Medicine PhysicianL800015935FL

General Provider Information

NPI Number : 1275552358
Entity Type Code : Organization
Provider Name (Legal Business Name) : COASTAL FAMILY PRACTICE LLC
Provider Business Mailing Address
First Line : 1404 S RIDGEWOOD AVE
Second Line :
City : EDGEWATER
State : FL
Zip : 32132-2720
Country : US
Telephone Number : 386-426-8166
Fax Number : 386-426-6399
Provider Business Practice Location Address
First Line : 1404 S RIDGEWOOD AVE
Second Line :
City : EDGEWATER
State : FL
Zip : 32132-2720
Country : US
Telephone Number : 386-426-8166
Fax Number : 386-426-6399
Authorized Official
Title or Position : PRACTICE MANAGER
Name : PAM LACEY
Credential :
Telephone Number : 386-761-6044
Provider Enumeration Date : 07/19/2006
Last Update Date : 11/09/2009

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Directions to “COASTAL FAMILY PRACTICE LLC ” Practice Location

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