Provider Demographics
NPI:1255723375
Name:COAST TO COAST WISCONSIN LLC
Entity type:Organization
Organization Name:COAST TO COAST WISCONSIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-855-9961
Mailing Address - Street 1:5195 HAMPSTED VILLAGE CENTER WAY
Mailing Address - Street 2:#256
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-8331
Mailing Address - Country:US
Mailing Address - Phone:614-855-9961
Mailing Address - Fax:
Practice Address - Street 1:410 DEWEY ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4715
Practice Address - Country:US
Practice Address - Phone:715-423-6060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty