Provider Demographics
NPI:1306436159
Name:A SUNCOAST LIFE, INC.
Entity type:Organization
Organization Name:A SUNCOAST LIFE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:FOURTHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-888-3111
Mailing Address - Street 1:1100 E BAY DR # G-78
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-2541
Mailing Address - Country:US
Mailing Address - Phone:239-888-3111
Mailing Address - Fax:
Practice Address - Street 1:1100 E BAY DR # G-78
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2541
Practice Address - Country:US
Practice Address - Phone:239-888-3111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1689090979Medicaid