Provider Demographics
NPI:1053189662
Name:COASTAL RIVER WELLNESS OF ALABAMA
Entity type:Organization
Organization Name:COASTAL RIVER WELLNESS OF ALABAMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:ELISABETH
Authorized Official - Last Name:SHEPPARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-510-8134
Mailing Address - Street 1:9560 GALLOPS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WILMER
Mailing Address - State:AL
Mailing Address - Zip Code:36587-9300
Mailing Address - Country:US
Mailing Address - Phone:251-510-8134
Mailing Address - Fax:
Practice Address - Street 1:620 HIGHWAY 43 S STE F
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-3603
Practice Address - Country:US
Practice Address - Phone:251-510-8134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-13
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty