Provider Demographics
NPI:1366469975
Name:COASTAL CARE CORPORATION
Entity Type:Organization
Organization Name:COASTAL CARE CORPORATION
Other - Org Name:CLEVELAND CLINIC IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROB
Authorized Official - Middle Name:
Authorized Official - Last Name:LORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-223-4903
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0959
Mailing Address - Country:US
Mailing Address - Phone:772-223-4903
Mailing Address - Fax:772-223-5622
Practice Address - Street 1:2100 SE SALERNO RD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6503
Practice Address - Country:US
Practice Address - Phone:772-223-5767
Practice Address - Fax:772-223-5622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4102261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCA5218OtherRR MEDICARE
FL064696201Medicaid
FLCA5218OtherRR MEDICARE