Provider Demographics
NPI:1124751185
Name:COASTAL CARE CORPORATION
Entity type:Organization
Organization Name:COASTAL CARE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER AND CONTRO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-636-7416
Mailing Address - Street 1:6801 BRECKSVILLE RD
Mailing Address - Street 2:STE 20, RK2-7
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131
Mailing Address - Country:US
Mailing Address - Phone:216-636-4969
Mailing Address - Fax:
Practice Address - Street 1:10000 SW INNOVATION WAY
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2111
Practice Address - Country:US
Practice Address - Phone:772-345-5236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)