Provider Demographics
NPI:1477637205
Name:COAST HEALTHCARE SUPPLY
Entity Type:Organization
Organization Name:COAST HEALTHCARE SUPPLY
Other - Org Name:KAREN MARKARD JENKINS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-964-1112
Mailing Address - Street 1:190 E ELM ST
Mailing Address - Street 2:P.O. BOX 1330
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-3026
Mailing Address - Country:US
Mailing Address - Phone:707-964-1112
Mailing Address - Fax:707-964-1222
Practice Address - Street 1:190 E ELM ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-3026
Practice Address - Country:US
Practice Address - Phone:707-964-1112
Practice Address - Fax:707-964-1222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102629332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME1708FMedicaid
CA0324230001Medicare NSC