Provider Demographics
NPI:1992273510
Name:COFFEESTONE HOLDINGS
Entity type:Organization
Organization Name:COFFEESTONE HOLDINGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTEL
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:SAMUELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-673-3111
Mailing Address - Street 1:14505 COMMERCE WAY STE 800
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1599
Mailing Address - Country:US
Mailing Address - Phone:305-821-8861
Mailing Address - Fax:305-821-8783
Practice Address - Street 1:14505 COMMERCE WAY STE 800
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-1599
Practice Address - Country:US
Practice Address - Phone:305-821-8861
Practice Address - Fax:305-821-8783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty