Provider Demographics
NPI:1982656070
Name:COAST TO COAST DIAGNOSTIC INC
Entity Type:Organization
Organization Name:COAST TO COAST DIAGNOSTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIBEL
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-642-0017
Mailing Address - Street 1:138 BEACOM BLVD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-1534
Mailing Address - Country:US
Mailing Address - Phone:305-642-0017
Mailing Address - Fax:305-642-2731
Practice Address - Street 1:138 BEACOM BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-1534
Practice Address - Country:US
Practice Address - Phone:305-642-0017
Practice Address - Fax:305-642-2731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC5623293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU3214Medicare PIN