Provider Demographics
NPI:1093191397
Name:COASTAL ER III, LLC
Entity type:Organization
Organization Name:COASTAL ER III, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-991-0912
Mailing Address - Street 1:PO BOX 6040
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-6040
Mailing Address - Country:US
Mailing Address - Phone:361-723-0226
Mailing Address - Fax:512-852-4625
Practice Address - Street 1:1860 HIGHWAY 181 FRONTAGE ROAD
Practice Address - Street 2:STE C
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374
Practice Address - Country:US
Practice Address - Phone:361-991-0912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-10
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care