Organization
COASTAL PODIATRY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TAMIKA MICHELLE BOLDEN RAVENELL DPM (DPM/ OWNER)
(916) 215-1234
Entity
Organization
Contact information
Practice address
180 WINGO WAY, SUITE 201, MOUNT PLEASANT, SC 29464-1810
(843) 856-5337
(843) 606-2483
Mailing address
PO BOX 783, MOUNT PLEASANT, SC 29465-0783
(916) 215-1234
(843) 606-2483
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
POD 607
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GP9889
—
SC
Enumeration date
11/07/2010
Last updated
12/13/2013
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