Provider Demographics
NPI:1770635039
Name:COASTAL PLAINS COMMUNITY MHMR CENTER
Entity Type:Organization
Organization Name:COASTAL PLAINS COMMUNITY MHMR CENTER
Other - Org Name:COASTAL PLAINS COMMUNITY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DURAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-777-3991
Mailing Address - Street 1:200 MARRIOTT DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-2213
Mailing Address - Country:US
Mailing Address - Phone:361-777-3991
Mailing Address - Fax:361-777-0610
Practice Address - Street 1:200 MARRIOTT DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-2213
Practice Address - Country:US
Practice Address - Phone:361-777-3991
Practice Address - Fax:361-777-0610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126843503Medicaid