Provider Demographics
NPI:1184990863
Name:COASTAL CAROLINA BEHAVIORAL HEALTHCARE LLC
Entity type:Organization
Organization Name:COASTAL CAROLINA BEHAVIORAL HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:TRAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-640-3535
Mailing Address - Street 1:603 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-4129
Mailing Address - Country:US
Mailing Address - Phone:910-640-3535
Mailing Address - Fax:910-640-3538
Practice Address - Street 1:603 S MADISON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-4129
Practice Address - Country:US
Practice Address - Phone:910-640-3535
Practice Address - Fax:910-640-3538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008752Medicaid
NC6604437Medicaid
NC8301226Medicaid
NC8301226VMedicaid
NC3410191Medicaid
NC8301226BMedicaid
NC8301226HMedicaid