Provider Demographics
NPI:1750632030
Name:SCI-COASTAL HOUSE I AND II
Entity Type:Organization
Organization Name:SCI-COASTAL HOUSE I AND II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-734-7398
Mailing Address - Street 1:PO BOX 1636
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27533-1636
Mailing Address - Country:US
Mailing Address - Phone:919-734-7398
Mailing Address - Fax:
Practice Address - Street 1:1974 W LAKESHORE DRIVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6856
Practice Address - Country:US
Practice Address - Phone:910-762-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SKILL CREATIONS INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-26
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-065-028313M00000X, 315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406250Medicaid