Provider Demographics
NPI:1891741377
Name:COASTAL DIAGNOSTIC IMAGING, PLLC
Entity type:Organization
Organization Name:COASTAL DIAGNOSTIC IMAGING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-300-0101
Mailing Address - Street 1:4300 N POINT PKWY
Mailing Address - Street 2:CREDENTIALING DEPT
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-4102
Mailing Address - Country:US
Mailing Address - Phone:770-300-0101
Mailing Address - Fax:770-300-0429
Practice Address - Street 1:3606 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5217
Practice Address - Country:US
Practice Address - Phone:910-937-7226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2183987AMedicare ID - Type Unspecified