Provider Demographics
NPI:1437459732
Name:COASTAL FOOT CENTER LLC
Entity Type:Organization
Organization Name:COASTAL FOOT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:251-626-6550
Mailing Address - Street 1:9912 DIMITRIOS BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-9569
Mailing Address - Country:US
Mailing Address - Phone:251-626-6550
Mailing Address - Fax:833-254-2641
Practice Address - Street 1:9912 DIMITRIOS AVE
Practice Address - Street 2:STE 103
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-9569
Practice Address - Country:US
Practice Address - Phone:251-626-6550
Practice Address - Fax:833-254-2641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102G484820Medicare PIN
AL6477040001Medicare NSC