Provider Demographics
NPI:1366746695
Name:FIRST COAST MOBILITY LLC
Entity type:Organization
Organization Name:FIRST COAST MOBILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:VAN KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-829-2846
Mailing Address - Street 1:3975 STATE ROAD 16
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-0730
Mailing Address - Country:US
Mailing Address - Phone:904-829-2846
Mailing Address - Fax:
Practice Address - Street 1:3975 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-0730
Practice Address - Country:US
Practice Address - Phone:904-829-2846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies