Provider Demographics
NPI:1336124270
Name:COASTAL PLAINS HOME HEALTH AGENCY 9A
Entity type:Organization
Organization Name:COASTAL PLAINS HOME HEALTH AGENCY 9A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:ADCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:CPA CIA CFE
Authorized Official - Phone:601-576-7853
Mailing Address - Street 1:1102 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2504
Mailing Address - Country:US
Mailing Address - Phone:228-867-6115
Mailing Address - Fax:228-867-6185
Practice Address - Street 1:1102 45TH AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2504
Practice Address - Country:US
Practice Address - Phone:228-867-6115
Practice Address - Fax:228-867-6185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3481251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00070500Medicaid
MS00070500Medicaid