Provider Demographics
NPI:1639705387
Name:COASTAL REGENEX LTD
Entity Type:Organization
Organization Name:COASTAL REGENEX LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:757-297-6750
Mailing Address - Street 1:182 ODD RD
Mailing Address - Street 2:
Mailing Address - City:POQUOSON
Mailing Address - State:VA
Mailing Address - Zip Code:23662-2035
Mailing Address - Country:US
Mailing Address - Phone:757-297-6750
Mailing Address - Fax:757-609-3473
Practice Address - Street 1:1013 EDEN WAY N STE B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2792
Practice Address - Country:US
Practice Address - Phone:757-297-6750
Practice Address - Fax:757-609-3473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty