Provider Demographics
NPI:1457534661
Name:COASTAL ORTHOPEDIC CENTER, INC
Entity Type:Organization
Organization Name:COASTAL ORTHOPEDIC CENTER, INC
Other - Org Name:COASTAL LIMBS & BRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:772-871-9200
Mailing Address - Street 1:510 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1943
Mailing Address - Country:US
Mailing Address - Phone:772-871-9200
Mailing Address - Fax:772-336-4040
Practice Address - Street 1:510 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1943
Practice Address - Country:US
Practice Address - Phone:772-871-9200
Practice Address - Fax:772-336-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPRO84335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0303990003Medicare NSC