Healthcare Provider Details

I. General information

NPI: 1942138839
Provider Name (Legal Business Name): COASTLINE CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101B VILLA DRIVE SUITE 226
DAPHNE AL
36526
US

IV. Provider business mailing address

101B VILLA DRIVE SUITE 226
DAPHNE AL
36526
US

V. Phone/Fax

Practice location:
  • Phone: 251-615-0000
  • Fax:
Mailing address:
  • Phone: 251-615-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MARCUS HAMILTON LACKEY
Title or Position: FOUNDER
Credential: MD
Phone: 251-615-0000