Provider Demographics
NPI:1336772292
Name:COASTAL COMMUNITY CARE LLC
Entity Type:Organization
Organization Name:COASTAL COMMUNITY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CASSAUNDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:NANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-319-5693
Mailing Address - Street 1:731 AIRPORT RD STE G
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4031
Mailing Address - Country:US
Mailing Address - Phone:850-852-1058
Mailing Address - Fax:850-852-1059
Practice Address - Street 1:731 AIRPORT RD STE G
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4031
Practice Address - Country:US
Practice Address - Phone:850-852-1058
Practice Address - Fax:850-852-1059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-19
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1336772292Medicaid