Provider Demographics
NPI:1336927870
Name:COASTAL CARE RESIDENCE LLC
Entity Type:Organization
Organization Name:COASTAL CARE RESIDENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHEVELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:727-674-1800
Mailing Address - Street 1:235 APOLLO BEACH BLVD # 182
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-2251
Mailing Address - Country:US
Mailing Address - Phone:727-417-1723
Mailing Address - Fax:
Practice Address - Street 1:216 APOLLO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572
Practice Address - Country:US
Practice Address - Phone:727-674-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-18
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities