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?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty