Provider Demographics
NPI:1508263575
Name:COASTAL THERAPEUTICS, INC
Entity Type:Organization
Organization Name:COASTAL THERAPEUTICS, INC
Other - Org Name:COASTAL THERAPEUTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STARLA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-633-6235
Mailing Address - Street 1:28260 US HIGHWAY 98
Mailing Address - Street 2:STE 4
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-7075
Mailing Address - Country:US
Mailing Address - Phone:251-626-5691
Mailing Address - Fax:
Practice Address - Street 1:28260 US HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7075
Practice Address - Country:US
Practice Address - Phone:251-626-5691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL THERAPEUTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-19
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL00935005Medicaid
AL51511102OtherBCBS