Provider Demographics
NPI:1689052359
Name:COASTAL VEIN & VASCULAR INSTITUTE, LLC
Entity Type:Organization
Organization Name:COASTAL VEIN & VASCULAR INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:W
Authorized Official - Last Name:MORI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-399-5550
Mailing Address - Street 1:3599 UNIVERSITY BLVD S
Mailing Address - Street 2:BLDG 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4252
Mailing Address - Country:US
Mailing Address - Phone:904-399-5550
Mailing Address - Fax:904-346-4334
Practice Address - Street 1:7741 POINT MEADOWS DR
Practice Address - Street 2:UNIT 104-106
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9182
Practice Address - Country:US
Practice Address - Phone:904-399-5550
Practice Address - Fax:904-346-4334
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DRS. MORI, BEAN & BROOKS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-13
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty