Provider Demographics
NPI:1912262411
Name:COASTAL CARE SERVICES LLC
Entity Type:Organization
Organization Name:COASTAL CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GROS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:504-616-7902
Mailing Address - Street 1:1011 N CAUSEWAY BLVD
Mailing Address - Street 2:SUITE 35
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3243
Mailing Address - Country:US
Mailing Address - Phone:985-674-2054
Mailing Address - Fax:985-674-2053
Practice Address - Street 1:1011 N CAUSEWAY BLVD
Practice Address - Street 2:SUITE 35
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3243
Practice Address - Country:US
Practice Address - Phone:985-674-2054
Practice Address - Fax:985-674-2053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACM 27024251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1802671Medicaid