Provider Demographics
NPI:1811990757
Name:COASTAL MANOR CORPORATION
Entity type:Organization
Organization Name:COASTAL MANOR CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OREY
Authorized Official - Middle Name:F
Authorized Official - Last Name:GADWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-846-5013
Mailing Address - Street 1:20 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-8412
Mailing Address - Country:US
Mailing Address - Phone:207-846-5013
Mailing Address - Fax:207-846-2252
Practice Address - Street 1:20 W MAIN ST
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-8412
Practice Address - Country:US
Practice Address - Phone:207-846-5013
Practice Address - Fax:207-846-2252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36175313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME141P10285OtherMEDICARE PART A
ME205157OtherMEDICARE PTAN
ME040823OtherANTHEM BC
ME115010000Medicaid