Provider Demographics
NPI:1558528521
Name:COSTON ENTERPRISES
Entity Type:Organization
Organization Name:COSTON ENTERPRISES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DIANO
Authorized Official - Middle Name:R
Authorized Official - Last Name:COSTON
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:813-383-4674
Mailing Address - Street 1:PO BOX 2232
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33595-2232
Mailing Address - Country:US
Mailing Address - Phone:813-383-4674
Mailing Address - Fax:813-383-4674
Practice Address - Street 1:1907 LANDSIDE DR
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-4421
Practice Address - Country:US
Practice Address - Phone:813-383-4674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL992277600Medicaid