Provider Demographics
NPI:1679581599
Name:COASTAL FAMILY HEALTH CENTER, INC.
Entity type:Organization
Organization Name:COASTAL FAMILY HEALTH CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELIQUE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GREER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-374-2494
Mailing Address - Street 1:10467 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4634
Mailing Address - Country:US
Mailing Address - Phone:228-374-2494
Mailing Address - Fax:228-374-0856
Practice Address - Street 1:4770 AMOCO DR
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-9627
Practice Address - Country:US
Practice Address - Phone:228-474-9511
Practice Address - Fax:228-474-9509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC00895OtherMEDICARE
MS04478868Medicaid
MS04478868Medicaid