Provider Demographics
NPI:1164606067
Name:COASTAL ORTHOPEDIC PRODUCTS, INC.
Entity Type:Organization
Organization Name:COASTAL ORTHOPEDIC PRODUCTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:912-258-2025
Mailing Address - Street 1:1479 BROCKETT RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-7326
Mailing Address - Country:US
Mailing Address - Phone:912-258-2025
Mailing Address - Fax:912-638-6115
Practice Address - Street 1:1900 SECOND STREET
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520
Practice Address - Country:US
Practice Address - Phone:912-258-2025
Practice Address - Fax:912-638-6115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies