Provider Demographics
NPI:1467610113
Name:WEST COAST AIDS FOUNDATION
Entity Type:Organization
Organization Name:WEST COAST AIDS FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:W
Authorized Official - Last Name:LAARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-669-6800
Mailing Address - Street 1:1840 MEASE DRIVE
Mailing Address - Street 2:SUITE 319
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-6605
Mailing Address - Country:US
Mailing Address - Phone:727-669-6800
Mailing Address - Fax:
Practice Address - Street 1:8607 EASTHAVEN COURT
Practice Address - Street 2:SUITE 101
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-5217
Practice Address - Country:US
Practice Address - Phone:727-669-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6817831-00251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6932118-00Medicaid