Provider Demographics
NPI:1932101227
Name:COASTAL ORTHOTICS AND PROSTHETICS LLC
Entity Type:Organization
Organization Name:COASTAL ORTHOTICS AND PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTHEY
Authorized Official - Suffix:
Authorized Official - Credentials:CP/COF
Authorized Official - Phone:985-626-1135
Mailing Address - Street 1:4600 HIGHWAY 22
Mailing Address - Street 2:STE 1
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-2891
Mailing Address - Country:US
Mailing Address - Phone:985-626-1135
Mailing Address - Fax:985-626-1174
Practice Address - Street 1:4600 HIGHWAY 22
Practice Address - Street 2:STE 1
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-2891
Practice Address - Country:US
Practice Address - Phone:985-626-1135
Practice Address - Fax:985-626-1174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06484500Medicaid
LAG5261OtherBLUE CROSS/BLUE SHIELD
LA1116726Medicaid
LAG5261OtherBLUE CROSS/BLUE SHIELD