Provider Demographics
NPI:1922468156
Name:COASTAL ER IV LLC
Entity Type:Organization
Organization Name:COASTAL ER IV LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KENYON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-994-1911
Mailing Address - Street 1:7750 SOUTH PADRE ISLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412
Mailing Address - Country:US
Mailing Address - Phone:361-994-1911
Mailing Address - Fax:
Practice Address - Street 1:7750 SOUTH PADRE ISLAND DRIVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412
Practice Address - Country:US
Practice Address - Phone:361-994-1911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-01
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8172261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH8172OtherMEDICAL LICENSE