1558320556 NPI number — COASTAL CARE CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558320556 NPI number — COASTAL CARE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL CARE CORPORATION
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:
1558320556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6801 BRECKSVILLE RD
Provider Second Line Business Mailing Address:
STE 20 ATTN: DPC RK2-7
Provider Business Mailing Address City Name:
INDEPENDENCE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44131-5062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-636-4969
Provider Business Mailing Address Fax Number:
216-636-6063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1095 NW SAINT LUCIE WEST BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34986-1719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-785-5502
Provider Business Practice Location Address Fax Number:
772-223-5622
Provider Enumeration Date:
03/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LARAWAY
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VP CHIEF FINANCE OFFICER
Authorized Official Telephone Number:
216-445-1343

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0206X , with the licence number: 4102 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X , with the licence number: 4102 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CA5218 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V2390 . This is a "BLUE CROSS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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