Provider Demographics
NPI:1912576893
Name:COASTAL LONGEVITY LLC
Entity Type:Organization
Organization Name:COASTAL LONGEVITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LUCAS
Authorized Official - Last Name:GAMBILL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:804-840-8522
Mailing Address - Street 1:3128 KLINE DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-6226
Mailing Address - Country:US
Mailing Address - Phone:804-840-8522
Mailing Address - Fax:
Practice Address - Street 1:3128 KLINE DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-6226
Practice Address - Country:US
Practice Address - Phone:804-840-8522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service