Provider Demographics
NPI:1609697242
Name:COASTAL ER XII, LLC
Entity type:Organization
Organization Name:COASTAL ER XII, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:LORIN
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-851-6626
Mailing Address - Street 1:4141 S STAPLES ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2115
Mailing Address - Country:US
Mailing Address - Phone:361-851-6626
Mailing Address - Fax:361-854-7204
Practice Address - Street 1:9422 SPRING GREEN BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-3810
Practice Address - Country:US
Practice Address - Phone:346-615-0919
Practice Address - Fax:346-615-0920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care