Provider Demographics
NPI:1750694170
Name:COASTAL NUTRITION, LLC
Entity type:Organization
Organization Name:COASTAL NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NUTRITIONIST
Authorized Official - Prefix:MS
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KAUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS LDN CDE
Authorized Official - Phone:910-762-9701
Mailing Address - Street 1:1612 DOCTORS CIR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7406
Mailing Address - Country:US
Mailing Address - Phone:910-762-9701
Mailing Address - Fax:910-762-9705
Practice Address - Street 1:1612 DOCTORS CIR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7406
Practice Address - Country:US
Practice Address - Phone:910-762-9701
Practice Address - Fax:910-762-9705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL000491261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health