Provider Demographics
NPI:1740214402
Name:COAST TO COAST MEDICAL, LLC
Entity Type:Organization
Organization Name:COAST TO COAST MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:870-732-0332
Mailing Address - Street 1:2201 HORIZON DRIVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301
Mailing Address - Country:US
Mailing Address - Phone:870-732-0332
Mailing Address - Fax:870-732-3078
Practice Address - Street 1:2201 HORIZON DRIVE
Practice Address - Street 2:SUITE 4
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:870-732-0332
Practice Address - Fax:870-732-3078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C471OtherAR BCBS GROUP #
AR5C471OtherAR BCBS GROUP #