Provider Demographics
NPI:1093432445
Name:COAST TO COAST MEDICAL WELLNESS, PLLC
Entity Type:Organization
Organization Name:COAST TO COAST MEDICAL WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:BREVETTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-575-8907
Mailing Address - Street 1:1500 ROUTE 112 BLDG 8
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8054
Mailing Address - Country:US
Mailing Address - Phone:631-343-4184
Mailing Address - Fax:
Practice Address - Street 1:150 BROADHOLLOW RD STE 222
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4901
Practice Address - Country:US
Practice Address - Phone:631-343-4184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty