# COASTAL ESTHETICS, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Coastline Primary Care
- **Organization subpart:** No

## Provider details

- **NPI number:** 1114572245
- **Authorized official:** CARISSA PETERSON APRN (OWNER/APRN)
- **Authorized official phone:** (386) 957-4100

## Contact information

- **Practice address:** 109 W KNAPP AVE, EDGEWATER, FL 32132-1555
- **Practice address phone:** (386) 957-4100
- **Practice address fax:** (386) 957-4104
- **Mailing address:** 109 W KNAPP AVE, EDGEWATER, FL 32132-1555
- **Mailing address phone:** (386) 957-4100
- **Mailing address fax:** (386) 957-4104

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207QA0505X | Adult Medicine Physician | — | NULL | Yes |
| 207QA0505X | Adult Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 08/06/2019
- **Last updated:** 04/26/2022