Provider Demographics
NPI:1033776919
Name:SOUTH COAST HOME LLC
Entity Type:Organization
Organization Name:SOUTH COAST HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:
Authorized Official - Last Name:KWIATKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-998-9349
Mailing Address - Street 1:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:MACATAWA
Mailing Address - State:MI
Mailing Address - Zip Code:49434-0029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:72633 M 43
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-8734
Practice Address - Country:US
Practice Address - Phone:269-998-9349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-25
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities