1134583305 NPI number — COASTAL FAMILY HEALTH CENTER INC

Table of content: (NPI 1134583305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134583305 NPI number — COASTAL FAMILY HEALTH CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL FAMILY HEALTH CENTER INC
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:
COASTAL FAMILY HEALTH CENTER GULFPORT
Provider Other Organization Name Type Code:
3
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:
1134583305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1046 DIVISION STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BILOXI
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-374-2494
Provider Business Mailing Address Fax Number:
228-374-2713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9113 HIGHWAY 49 STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39503-4330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-374-2494
Provider Business Practice Location Address Fax Number:
228-374-2713
Provider Enumeration Date:
04/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DUNAWAY
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
288-374-2494

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  CS14729 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9013185 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2159236 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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