Healthcare Provider Details

I. General information

NPI: 1336927870
Provider Name (Legal Business Name): COASTAL CARE RESIDENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 05/06/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 APOLLO BEACH BLVD
APOLLO BEACH FL
33572
US

IV. Provider business mailing address

235 APOLLO BEACH BLVD # 182
APOLLO BEACH FL
33572-2251
US

V. Phone/Fax

Practice location:
  • Phone: 727-674-1800
  • Fax:
Mailing address:
  • Phone: 727-417-1723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHEVELLE R JORDAN
Title or Position: OWNER
Credential: RN
Phone: 727-674-1800