Provider Demographics
NPI:1063996734
Name:COASTAL ENDO, LLC
Entity type:Organization
Organization Name:COASTAL ENDO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-609-1168
Mailing Address - Street 1:175 GUNNING RIVER RD UNIT 4
Mailing Address - Street 2:
Mailing Address - City:BARNEGAT
Mailing Address - State:NJ
Mailing Address - Zip Code:08005-1436
Mailing Address - Country:US
Mailing Address - Phone:609-698-0700
Mailing Address - Fax:609-698-0777
Practice Address - Street 1:175 GUNNING RIVER RD UNIT 4
Practice Address - Street 2:
Practice Address - City:BARNEGAT
Practice Address - State:NJ
Practice Address - Zip Code:08005-1436
Practice Address - Country:US
Practice Address - Phone:609-698-0700
Practice Address - Fax:609-698-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical