Healthcare Provider Details

I. General information

NPI: 1194635185
Provider Name (Legal Business Name): COASTAL COMMUNITY SENIOR LIVING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3755 MAIN ST UNIT 101
COLLEGE PARK GA
30337-3543
US

IV. Provider business mailing address

3755 MAIN ST UNIT 101
COLLEGE PARK GA
30337-3543
US

V. Phone/Fax

Practice location:
  • Phone: 844-690-4494
  • Fax: 855-538-9242
Mailing address:
  • Phone: 844-690-4494
  • Fax: 855-538-9242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NOVELLA TASCOE
Title or Position: OWNER
Credential:
Phone: 844-690-4494