MEDICARE: COASTAL DIABETES, 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1730494451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL DIABETES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 242037
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36124-2037
Country	:	US
Telephone Number	:	334-396-3273
Fax Number	:	334-396-4905

Provider Business Practice Location Address
First Line	:	12 MIRACLE STRIP PKWY SE
Second Line	:	SUITE 102
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5814
Country	:	US
Telephone Number	:	850-243-0483
Fax Number	:	850-243-1421

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ANTHONY ROWLAND
Credential	:
Telephone Number	:	850-243-0483

Provider Enumeration Date	:	08/18/2010
Last Update Date	:	08/18/2010

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