Provider Demographics
NPI:1194873018
Name:COASTAL CARE CORPORATION
Entity type:Organization
Organization Name:COASTAL CARE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LITKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-223-4940
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-5665
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:11600 SE FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:HOBE SOUND
Practice Address - State:FL
Practice Address - Zip Code:33455-5213
Practice Address - Country:US
Practice Address - Phone:772-223-4940
Practice Address - Fax:772-223-4944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1996125033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064696202Medicaid
FL064696202Medicaid
FL98491Medicare PIN