Provider Demographics
NPI:1598916611
Name:PARADISE COAST PAVILION, LLC
Entity Type:Organization
Organization Name:PARADISE COAST PAVILION, LLC
Other - Org Name:VEIN CARE PAVILION OF FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-854-3333
Mailing Address - Street 1:447 N BELAIR RD STE 103
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3091
Mailing Address - Country:US
Mailing Address - Phone:706-854-3333
Mailing Address - Fax:706-854-2059
Practice Address - Street 1:9400 GLADIOLUS DR
Practice Address - Street 2:SUITE 105
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-6699
Practice Address - Country:US
Practice Address - Phone:239-454-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME23742208200000X
FLME1028152086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty