| Entity Name: | COASTAL FAMILY PRACTICE, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 28 Jul 2000 (25 years ago) |
| Document Number: | L00000009057 |
| FEI/EIN Number | 593659218 |
| Address: | 1404 S RIDGEWOOD AVE., EDGEWATER, FL, 32132-2720, US |
| Mail Address: | 1404 S RIDGEWOOD AVE., EDGEWATER, FL, 32132-2720, US |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1275552358 | 2006-07-19 | 2009-11-09 | 1404 S RIDGEWOOD AVE, EDGEWATER, FL, 321322720, US | 1404 S RIDGEWOOD AVE, EDGEWATER, FL, 321322720, US | |||||||||||||||||||
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| Phone | +1 386-426-8166 |
| Fax | 3864266399 |
Authorized person
| Name | PAM LACEY |
| Role | PRACTICE MANAGER |
| Phone | 3867616044 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | L800015935 |
| State | FL |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| FREDETTE PATRICIA | Agent | 1404 S RIDGEWOOD AVE., EDGEWATER, FL, 321322720 |
| Name | Role | Address |
|---|---|---|
| FREDETTE PATRICIA | Managing Member | 1404 S. RIDGEWOOD AVE., EDGEWATER, FL, 321322720 |
| CHANG MARGARET | Managing Member | 1404 S. RIDGEWOOD AVE, EDGEWATER, FL, 321322720 |
| Buchanan Sandra | Managing Member | 1404 S RIDGEWOOD AVE., EDGEWATER, FL, 321322720 |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
