Provider Demographics
NPI:1659648152
Name:COASTAL PODIATRY, LLC
Entity Type:Organization
Organization Name:COASTAL PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMIKA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BOLDEN RAVENELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:916-215-1234
Mailing Address - Street 1:PO BOX 783
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29465-0783
Mailing Address - Country:US
Mailing Address - Phone:916-215-1234
Mailing Address - Fax:843-606-2483
Practice Address - Street 1:180 WINGO WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-1810
Practice Address - Country:US
Practice Address - Phone:916-215-1234
Practice Address - Fax:843-606-2483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC607213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty