MEDICARE: COASTAL CARE CORPORATION

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	207Q00000X	Family Medicine Physician	1998122013	FL
2	261QU0200X	Urgent Care Clinic/Center	1998122013	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568510618
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CARE CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 417
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34995-0417
Country	:	US
Telephone Number	:	772-223-2832
Fax Number	:	772-223-5646

Provider Business Practice Location Address
First Line	:	3066 SW MARTIN DOWNS BLVD
Second Line	:	UNIT 6 STE B
City	:	PALM CITY
State	:	FL
Zip	:	34990-2683
Country	:	US
Telephone Number	:	772-781-2781
Fax Number	:	772-781-2782

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT LESTER LORD
Credential	:
Telephone Number	:	772-223-5945

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	10/03/2019

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Directions to “COASTAL CARE CORPORATION ” Practice Location

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