Provider Demographics
NPI: | 1790401016 |
---|---|
Name: | COAST SPINE AND SPORTS MEDICINE PLLC |
Entity Type: | Organization |
Organization Name: | COAST SPINE AND SPORTS MEDICINE PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | ACCESS MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | SANDY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | CLEMENS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 206-538-6300 |
Mailing Address - Street 1: | 8012 112TH STREET CT E STE 120 |
Mailing Address - Street 2: | |
Mailing Address - City: | PUYALLUP |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98373-7856 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 253-648-1853 |
Mailing Address - Fax: | 425-800-9756 |
Practice Address - Street 1: | 8140 FREEDOM LN NE STE A |
Practice Address - Street 2: | |
Practice Address - City: | LACEY |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98516-4752 |
Practice Address - Country: | US |
Practice Address - Phone: | 253-648-1853 |
Practice Address - Fax: | 425-800-9756 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2022-10-18 |
Last Update Date: | 2022-10-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Single Specialty |