Provider Demographics
NPI:1457418311
Name:COASTAL REHABILITATION INC
Entity Type:Organization
Organization Name:COASTAL REHABILITATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:YAGER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:252-338-2114
Mailing Address - Street 1:101 MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909
Mailing Address - Country:US
Mailing Address - Phone:252-338-2114
Mailing Address - Fax:252-338-2115
Practice Address - Street 1:101 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-338-2114
Practice Address - Fax:252-338-2115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225100000X
225100000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0002WOtherBCBS FACILITY GROUP
NC07763OtherBCBS
NC3120758OtherONENET-OT
NC7207763Medicaid
NC2120758OtherONENET-PT
NC7200037Medicaid
NC07763OtherBCBS
NC2120758OtherONENET-PT