Provider Demographics
NPI:1912990235
Name:COASTAL NURSECARE INC.
Entity Type:Organization
Organization Name:COASTAL NURSECARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-264-0040
Mailing Address - Street 1:3216 SHRINE RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4325
Mailing Address - Country:US
Mailing Address - Phone:912-264-0040
Mailing Address - Fax:912-261-1292
Practice Address - Street 1:3216 SHRINE RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4325
Practice Address - Country:US
Practice Address - Phone:912-264-0040
Practice Address - Fax:912-261-1292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063-R-0004251E00000X, 251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251E00000XAgenciesHome Health
Not Answered251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52100796002OtherBC/BS
GA52100796002OtherBC/BS
GA=========OtherTRICARE