Provider Demographics
NPI:1538532221
Name:DIABETES CLINIC OF THE COAST, PLLC
Entity type:Organization
Organization Name:DIABETES CLINIC OF THE COAST, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELONIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:228-697-8244
Mailing Address - Street 1:PO BOX 863
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-0419
Mailing Address - Country:US
Mailing Address - Phone:228-220-1588
Mailing Address - Fax:228-220-1581
Practice Address - Street 1:1110 BROAD AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-8907
Practice Address - Country:US
Practice Address - Phone:228-220-1588
Practice Address - Fax:228-220-1581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR874839363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1285902841OtherNPI