Provider Demographics
NPI:1093727117
Name:COASTAL PROSTHETICS AND ORTHOTICS, LLC
Entity Type:Organization
Organization Name:COASTAL PROSTHETICS AND ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIVERD
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:757-892-5300
Mailing Address - Street 1:11818 ROCK LANDING DR
Mailing Address - Street 2:STE#104
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4230
Mailing Address - Country:US
Mailing Address - Phone:757-892-5300
Mailing Address - Fax:757-892-5303
Practice Address - Street 1:11818 ROCK LANDING DR
Practice Address - Street 2:STE#104
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4230
Practice Address - Country:US
Practice Address - Phone:757-892-5300
Practice Address - Fax:757-892-5303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9190414Medicaid
VA7703398Medicaid
VA39563OtherSENTARA
VA1029129OtherACM
VA194379OtherANTHEM BCBS
VA9190414Medicaid
VA7703398Medicaid