Provider Demographics
NPI:1619667565
Name:COASTAL HEALTH & WELLNESS
Entity Type:Organization
Organization Name:COASTAL HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AMI
Authorized Official - Middle Name:
Authorized Official - Last Name:COTHARN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:409-938-2218
Mailing Address - Street 1:PO BOX 939
Mailing Address - Street 2:
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-0939
Mailing Address - Country:US
Mailing Address - Phone:409-938-2218
Mailing Address - Fax:
Practice Address - Street 1:1805 13TH AVE N
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77590-5498
Practice Address - Country:US
Practice Address - Phone:409-938-2234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL HEALTH & WELLNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-05-12
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)