Provider Demographics
NPI:1487829842
Name:COASTAL FOOT CLINIC INC
Entity Type:Organization
Organization Name:COASTAL FOOT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PALECKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:225-718-5314
Mailing Address - Street 1:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:LA
Mailing Address - Zip Code:70755-0575
Mailing Address - Country:US
Mailing Address - Phone:225-718-5314
Mailing Address - Fax:225-618-0863
Practice Address - Street 1:230 ROBERTS DR
Practice Address - Street 2:SUITE G
Practice Address - City:NEW ROADS
Practice Address - State:LA
Practice Address - Zip Code:70760-2661
Practice Address - Country:US
Practice Address - Phone:225-638-6640
Practice Address - Fax:225-618-0863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD165R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1040180001Medicare NSC