Provider Demographics
NPI:1598895625
Name:COASTAL CAREGIVERS
Entity Type:Organization
Organization Name:COASTAL CAREGIVERS
Other - Org Name:JENNIFER POTTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LENNON
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:910-253-7581
Mailing Address - Street 1:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-0057
Mailing Address - Country:US
Mailing Address - Phone:910-253-7581
Mailing Address - Fax:910-253-7664
Practice Address - Street 1:3470 OLD OCEAN HWY
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-0057
Practice Address - Country:US
Practice Address - Phone:910-253-7581
Practice Address - Fax:910-253-7664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3358251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601493Medicaid