MEDICARE: COASTAL RECOVERY & WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	DHEC OTP-092	SC
2	101YA0400X	Addiction (Substance Use Disorder) Counselor		SC
3	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
4	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1386869337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL RECOVERY & WELLNESS, LLC

Provider Business Mailing Address
First Line	:	1113 44TH AVENUE NORTH
Second Line	:	SUITE 100
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577
Country	:	US
Telephone Number	:	843-449-6261
Fax Number	:	843-449-8171

Provider Business Practice Location Address
First Line	:	1113 44TH AVENUE NORTH
Second Line	:	SUITE 100
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577
Country	:	US
Telephone Number	:	843-449-6261
Fax Number	:	843-449-8171

Authorized Official
Title or Position	:	CEO
Name	:	MR. SPENCER JOSEY
Credential	:
Telephone Number	:	843-449-6261

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	10/27/2023

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