Provider Demographics
NPI:1235632449
Name:COASTAL GEORGIA WELLNESS CENTER AND FAMILY MEDICINE
Entity Type:Organization
Organization Name:COASTAL GEORGIA WELLNESS CENTER AND FAMILY MEDICINE
Other - Org Name:COASTAL GEORGIA WELLNESS CENTER & FAMILY MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CPPM
Authorized Official - Phone:912-576-7546
Mailing Address - Street 1:102 LAKESHORE DR STE B
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3875
Mailing Address - Country:US
Mailing Address - Phone:912-576-7546
Mailing Address - Fax:912-576-2348
Practice Address - Street 1:102 LAKESHORE DR STE B
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3875
Practice Address - Country:US
Practice Address - Phone:912-576-7546
Practice Address - Fax:912-576-2348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-14
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty