Provider Demographics
NPI:1972834760
Name:COASTAL FOOT & ANKLE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:COASTAL FOOT & ANKLE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-826-1900
Mailing Address - Street 1:1740 TREE BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-5720
Mailing Address - Country:US
Mailing Address - Phone:904-826-1900
Mailing Address - Fax:904-826-1920
Practice Address - Street 1:1740 TREE BLVD STE 112
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5720
Practice Address - Country:US
Practice Address - Phone:904-826-1900
Practice Address - Fax:904-826-1920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP02829213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000NUOtherBCBS OF FLORIDA
FL6326530001Medicare NSC
FLCV051AMedicare PIN