Provider Demographics
NPI:1750652566
Name:COASTAL HOME CARE, LLC
Entity Type:Organization
Organization Name:COASTAL HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BONACCORSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-962-9999
Mailing Address - Street 1:33 S STATE ST FL 5
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2804
Mailing Address - Country:US
Mailing Address - Phone:312-762-9999
Mailing Address - Fax:
Practice Address - Street 1:4501 ALTAMA AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-3008
Practice Address - Country:US
Practice Address - Phone:912-264-5363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063-R-0272253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000552538AKMedicaid