Provider Demographics
NPI:1992143614
Name:COASTALORTHOPEDIC CENTER, INC.
Entity type:Organization
Organization Name:COASTALORTHOPEDIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:772-871-9200
Mailing Address - Street 1:510 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1943
Mailing Address - Country:US
Mailing Address - Phone:772-871-9200
Mailing Address - Fax:772-336-4040
Practice Address - Street 1:710 NW PARK ST
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972-4155
Practice Address - Country:US
Practice Address - Phone:863-357-0079
Practice Address - Fax:772-336-4040
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTALORTHOPEDIC CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPRO84335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL200996001Medicaid
FL200996001Medicaid