Provider Demographics
NPI:1558132365
Name:COASTAL ER XI, LLC
Entity Type:Organization
Organization Name:COASTAL ER XI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:LORIN
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-851-6626
Mailing Address - Street 1:4141 S STAPLES ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2115
Mailing Address - Country:US
Mailing Address - Phone:361-851-6626
Mailing Address - Fax:
Practice Address - Street 1:12314 POTRANCO RD STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-4125
Practice Address - Country:US
Practice Address - Phone:210-981-3001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care