1164827093 NPI number — COASTAL ER II, LLC

Table of content: (NPI 1164827093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164827093 NPI number — COASTAL ER II, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL ER II, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164827093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6040
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78466-6040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-991-0911
Provider Business Mailing Address Fax Number:
512-852-4625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4141 S STAPLES ST
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78411-2105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-991-0911
Provider Business Practice Location Address Fax Number:
512-852-4625
Provider Enumeration Date:
11/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KWON
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
LLC BOARD MEMBER
Authorized Official Telephone Number:
361-991-0911

Provider Taxonomy Codes

  • Taxonomy code: 261QE0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 160169 . This is a "TDSHS FSEC LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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