MEDICARE: COASTAL CARE HEALTH SYSTEM, INC.

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	261QU0200X	Urgent Care Clinic/Center

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	:	1851950661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CARE HEALTH SYSTEM, INC.

Provider Business Mailing Address
First Line	:	8291 DANI DR STE 101A
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33966-8009
Country	:	US
Telephone Number	:	239-931-6049
Fax Number	:	239-931-4986

Provider Business Practice Location Address
First Line	:	8291 DANI DR STE 100
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33966-8021
Country	:	US
Telephone Number	:	239-931-6049
Fax Number	:	239-931-4986

Authorized Official
Title or Position	:	OWNER AND AO
Name	:	ANGELIA SAKYI-AGYEKUM
Credential	:	PA
Telephone Number	:	904-437-1529

Provider Enumeration Date	:	06/06/2019
Last Update Date	:	07/24/2023

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