Provider Demographics
NPI:1396010120
Name:COAST FAMILY CARE GROUP LLC
Entity Type:Organization
Organization Name:COAST FAMILY CARE GROUP LLC
Other - Org Name:COAST FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:VILCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-202-5314
Mailing Address - Street 1:2914 SUMMER SWAN DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-7404
Mailing Address - Country:US
Mailing Address - Phone:832-867-8019
Mailing Address - Fax:321-800-6129
Practice Address - Street 1:4100 S FERDON BLVD STE A4
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5287
Practice Address - Country:US
Practice Address - Phone:832-202-5314
Practice Address - Fax:281-220-8979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN 375208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty