Provider Demographics
NPI:1588111082
Name:COASTAL ER V, LLC
Entity type:Organization
Organization Name:COASTAL ER V, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LLC BOARD MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KENYON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-991-0811
Mailing Address - Street 1:PO BOX 6040
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-6040
Mailing Address - Country:US
Mailing Address - Phone:361-884-2904
Mailing Address - Fax:361-884-1912
Practice Address - Street 1:11158 LEOPARD ST STE 103
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-2612
Practice Address - Country:US
Practice Address - Phone:361-991-0811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX160281261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160281OtherTDSHS FEC LICENSE