Provider Demographics
NPI:1902970684
Name:COASTAL CARE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:COASTAL CARE MEDICAL CENTER INC
Other - Org Name:COASTAL CARE MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:D
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-642-3304
Mailing Address - Street 1:11761 BEACH BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-6615
Mailing Address - Country:US
Mailing Address - Phone:904-642-3304
Mailing Address - Fax:904-928-3561
Practice Address - Street 1:11761 BEACH BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-6615
Practice Address - Country:US
Practice Address - Phone:904-642-3304
Practice Address - Fax:904-928-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K0340Medicare ID - Type Unspecified
FL4625520001Medicare NSC