Provider Demographics
NPI:1033500624
Name:COASTAL FAMILY HEALTHCARE LLC
Entity Type:Organization
Organization Name:COASTAL FAMILY HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEVENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-437-4711
Mailing Address - Street 1:21 HOSPITAL DR
Mailing Address - Street 2:SUITE 280
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-2452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 HOSPITAL DR
Practice Address - Street 2:SUITE 280
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2452
Practice Address - Country:US
Practice Address - Phone:386-437-4711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty