Provider Demographics
NPI:1275178816
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:ADMINISTRATIVE EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIVERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-892-5300
Mailing Address - Street 1:433 NETWORK STA
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3851
Mailing Address - Country:US
Mailing Address - Phone:757-892-5300
Mailing Address - Fax:
Practice Address - Street 1:1134 N ROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3322
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:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA39563OtherSENTARA
VA9190414Medicaid
VA1029129OtherACM
VA434534OtherBCBS