Provider Demographics
NPI:1386619542
Name:COASTAL HOME CARE
Entity type:Organization
Organization Name:COASTAL HOME CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-8149
Mailing Address - Street 1:PO BOX 532549
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-2549
Mailing Address - Country:US
Mailing Address - Phone:843-821-8525
Mailing Address - Fax:843-821-0982
Practice Address - Street 1:4209 MAYFAIR ST
Practice Address - Street 2:SUITE B
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5899
Practice Address - Country:US
Practice Address - Phone:843-839-1649
Practice Address - Fax:843-839-1699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC65-006981332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDME115Medicaid
SCDME115Medicaid
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