Healthcare Provider Details

I. General information

NPI: 1255772695
Provider Name (Legal Business Name): COASTAL HOME CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2970 CLAIRMONT RD NE STE 305
BROOKHAVEN GA
30329-1638
US

IV. Provider business mailing address

33 S STATE ST FL 5
CHICAGO IL
60603-2804
US

V. Phone/Fax

Practice location:
  • Phone: 770-376-3133
  • Fax:
Mailing address:
  • Phone: 312-762-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number085-R-1045
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH BONACCORSI
Title or Position: CHIEF LEGAL OFFICER
Credential:
Phone: 312-762-9999