Provider Demographics
NPI:1285777490
Name:COASTAL HOME CARE, LLC
Entity type:Organization
Organization Name:COASTAL HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BONACCORSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-762-9999
Mailing Address - Street 1:33 S STATE ST FL 5
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2804
Mailing Address - Country:US
Mailing Address - Phone:312-762-9999
Mailing Address - Fax:912-355-8738
Practice Address - Street 1:3470 N VALDOSTA RD STE B
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1050
Practice Address - Country:US
Practice Address - Phone:229-671-9232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016R0270251E00000X
GA063R0272251E00000X
GA025R0271251E00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000609958PMedicaid