Provider Demographics
NPI:1316006075
Name:COASTALCARE
Entity Type:Organization
Organization Name:COASTALCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GLENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-550-2567
Mailing Address - Street 1:P.O. BOX 4147
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28406-1147
Mailing Address - Country:US
Mailing Address - Phone:910-550-2600
Mailing Address - Fax:910-550-2570
Practice Address - Street 1:3809 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6150
Practice Address - Country:US
Practice Address - Phone:910-550-2600
Practice Address - Fax:910-550-2570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 065-007251S00000X
NCMHL065007261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408379Medicaid
NC3404933Medicaid
NC0171Medicare ID - Type UnspecifiedGROUP PRICING NUMBER