Provider Demographics
NPI:1619318052
Name:COASTAL HOME CARE, LLC
Entity type:Organization
Organization Name:COASTAL HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BONACCORSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-762-9999
Mailing Address - Street 1:33 S STATE ST FL 5
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2804
Mailing Address - Country:US
Mailing Address - Phone:312-762-9999
Mailing Address - Fax:
Practice Address - Street 1:3885 CRESTWOOD PKWY NW STE 375
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-7165
Practice Address - Country:US
Practice Address - Phone:470-617-9401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-15
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 253Z00000X
GA085-R-1045251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA370024140AMedicaid
GA060-R-0226OtherPERMIT
GA000552538CCMedicaid