1538278536 NPI number — COASTAL CENTER, LLC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538278536 NPI number — COASTAL CENTER, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL CENTER, LLC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538278536
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 W. CENTRAL AVE,
Provider Second Line Business Mailing Address:
SUITE 290
Provider Business Mailing Address City Name:
COOS BAY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-267-2113
Provider Business Mailing Address Fax Number:
541-267-5071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
COOS BAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97420-2316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-267-2113
Provider Business Practice Location Address Fax Number:
541-267-5071
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOWELL
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
541-267-2113

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LCSW638 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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