Provider Demographics
NPI:1558328393
Name:COASTAL PROSTHETICS & ORTHOTICS
Entity Type:Organization
Organization Name:COASTAL PROSTHETICS & ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CPO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIVERD
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:757-892-5300
Mailing Address - Street 1:6330 N. CENTER DR.
Mailing Address - Street 2:BLDG 13. STE 125
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4009
Mailing Address - Country:US
Mailing Address - Phone:757-892-5300
Mailing Address - Fax:757-892-5303
Practice Address - Street 1:6330 N. CENTER DR.
Practice Address - Street 2:BLDG 13. STE 125
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4009
Practice Address - Country:US
Practice Address - Phone:757-892-5300
Practice Address - Fax:757-892-5303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA39563OtherSENTARA
VA434534OtherBCBS
VA7703398Medicaid
VA9190414Medicaid
VA1029129OtherACM
VA39563OtherSENTARA
VA39563OtherSENTARA