Provider Demographics
NPI:1487146890
Name:FIRST COAST MEDICAL NETWORK LLC
Entity type:Organization
Organization Name:FIRST COAST MEDICAL NETWORK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:COLEY-GROBES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-373-3435
Mailing Address - Street 1:1687 MAJESTIC VIEW LN
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-3223
Mailing Address - Country:US
Mailing Address - Phone:904-329-1391
Mailing Address - Fax:904-580-5835
Practice Address - Street 1:1532 KINGSLEY AVE STE 106
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4536
Practice Address - Country:US
Practice Address - Phone:904-329-1391
Practice Address - Fax:904-580-5835
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIRST COAST MEDICAL NETWORK, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-31
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213E00000X
FLL18000131637213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty