Provider Demographics
NPI:1144619560
Name:COAST URGENT CARE
Entity Type:Organization
Organization Name:COAST URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYFIELD JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-365-2363
Mailing Address - Street 1:PO BOX 7311
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-7201
Mailing Address - Country:US
Mailing Address - Phone:228-365-2363
Mailing Address - Fax:
Practice Address - Street 1:179 REYNOIR ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-3831
Practice Address - Country:US
Practice Address - Phone:228-365-2363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care