Provider Demographics
NPI:1780792705
Name:COASTAL RESIDENTIAL SERVICES, INC
Entity type:Organization
Organization Name:COASTAL RESIDENTIAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-938-9550
Mailing Address - Street 1:PO BOX 7128
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-2128
Mailing Address - Country:US
Mailing Address - Phone:910-938-9550
Mailing Address - Fax:910-346-9186
Practice Address - Street 1:445 WESTERN BLVD STE T
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6852
Practice Address - Country:US
Practice Address - Phone:910-938-9550
Practice Address - Fax:910-346-9186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-067-091320900000X, 251S00000X
NCMHL-067-052251S00000X, 320900000X
NCMHL-067-049251S00000X
NCMHL-067-059251S00000X, 320900000X
NCMHL-067049320900000X
NCMHL-067-085251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3419231Medicaid
NC3408942Medicaid
NC8702260Medicaid
NC8303573Medicaid
NC8303573Medicaid