Provider Demographics
NPI:1376873299
Name:COASTAL CAROLINA HOME CARE, LLC
Entity Type:Organization
Organization Name:COASTAL CAROLINA HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR / OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GENELL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SIKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-754-3445
Mailing Address - Street 1:PO BOX 3291
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459-3291
Mailing Address - Country:US
Mailing Address - Phone:910-754-3445
Mailing Address - Fax:910-754-3446
Practice Address - Street 1:117 HOLDEN BEACH RD.
Practice Address - Street 2:SUITE 101
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28459
Practice Address - Country:US
Practice Address - Phone:910-754-3445
Practice Address - Fax:910-754-3446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3013251E00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No251E00000XAgenciesHome Health