Provider Demographics
NPI:1316644156
Name:COASTAL COMMUNITY DIRECT PRIMARY CARE
Entity type:Organization
Organization Name:COASTAL COMMUNITY DIRECT PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAURENE
Authorized Official - Middle Name:
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:361-203-4969
Mailing Address - Street 1:1315 SANTA FE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-2241
Mailing Address - Country:US
Mailing Address - Phone:361-203-4969
Mailing Address - Fax:
Practice Address - Street 1:1315 SANTA FE ST STE 101
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2241
Practice Address - Country:US
Practice Address - Phone:361-203-4969
Practice Address - Fax:361-200-2092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty