Provider Demographics
NPI:1134485014
Name:COASTAL HOME CARE, LLC
Entity Type:Organization
Organization Name:COASTAL HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BONACCORSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-762-9999
Mailing Address - Street 1:33 S STATE ST STE 500
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2809
Mailing Address - Country:US
Mailing Address - Phone:312-795-4693
Mailing Address - Fax:312-704-0347
Practice Address - Street 1:6602 ABERCORN ST STE 200
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5849
Practice Address - Country:US
Practice Address - Phone:912-354-3680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000609958AUMedicaid