Provider Demographics
NPI:1689875403
Name:COASTAL OPTICAL CENTER INC
Entity Type:Organization
Organization Name:COASTAL OPTICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:PARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-283-8444
Mailing Address - Street 1:304 SE HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2338
Mailing Address - Country:US
Mailing Address - Phone:772-219-9185
Mailing Address - Fax:772-283-8456
Practice Address - Street 1:304 SE HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2338
Practice Address - Country:US
Practice Address - Phone:772-219-9185
Practice Address - Fax:772-283-8456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54986174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4459490001Medicare NSC