MEDICARE: COASTAL COMMUNITY HEALTH SERVICES, INC.

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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1811602378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL COMMUNITY HEALTH SERVICES, INC.

Provider Business Mailing Address
First Line	:	100 PROFESSIONAL CENTER DR
Second Line	:
City	:	BRUNSWICK
State	:	GA
Zip	:	31525-6743
Country	:	US
Telephone Number	:	912-275-8028
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 LAKESHORE DR
Second Line	:
City	:	SAINT MARYS
State	:	GA
Zip	:	31558-3876
Country	:	US
Telephone Number	:	912-275-8028
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KAVANAUGH CHANDLER
Credential	:
Telephone Number	:	912-275-8028

Provider Enumeration Date	:	01/19/2023
Last Update Date	:	01/19/2023

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