Provider Demographics
NPI:1053453258
Name:COASTAL ENTERPRISES OF WILMINGTON
Entity Type:Organization
Organization Name:COASTAL ENTERPRISES OF WILMINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IDD SERVICES COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:HOOVER
Authorized Official - Suffix:
Authorized Official - Credentials:BS, QP
Authorized Official - Phone:910-763-3424
Mailing Address - Street 1:1214 KIDDER ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-5918
Mailing Address - Country:US
Mailing Address - Phone:910-763-3424
Mailing Address - Fax:910-815-0367
Practice Address - Street 1:1214 KIDDER ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-5918
Practice Address - Country:US
Practice Address - Phone:910-763-3424
Practice Address - Fax:910-815-0367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-065-099251C00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL-065-099OtherMENTAL HEALTH LICENSE #