Provider Demographics
NPI:1699067959
Name:COASTAL PREVENTATIVE MEDICINE, LLC
Entity type:Organization
Organization Name:COASTAL PREVENTATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-296-2552
Mailing Address - Street 1:PO BOX 17708
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-7708
Mailing Address - Country:US
Mailing Address - Phone:601-296-2552
Mailing Address - Fax:601-296-2397
Practice Address - Street 1:3300 LADNIER RD
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5909
Practice Address - Country:US
Practice Address - Phone:228-497-2652
Practice Address - Fax:228-497-3667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
MS261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care