Provider Demographics
NPI:1790113520
Name:COASTAL CAROLINA BEHAVIORAL HEALTHCARE, LLC
Entity Type:Organization
Organization Name:COASTAL CAROLINA BEHAVIORAL HEALTHCARE, LLC
Other - Org Name:CIRCLE OF COURAGE BEHAVIORAL HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARONDA
Authorized Official - Middle Name:WOODS
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-769-3575
Mailing Address - Street 1:3806 PARK AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6739
Mailing Address - Country:US
Mailing Address - Phone:910-769-3575
Mailing Address - Fax:
Practice Address - Street 1:108 HAY ST STE 303
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5684
Practice Address - Country:US
Practice Address - Phone:910-769-3575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008752Medicaid
NC8301226Medicaid
NC8301226VMedicaid
NC6604437Medicaid
NC8301226BMedicaid
NC8301226HMedicaid
NC3410191Medicaid