Healthcare Provider Details

I. General information

NPI: 1104197920
Provider Name (Legal Business Name): COASTAL HOME CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 VIRGINIA ST
COLUMBUS GA
31901-2569
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 706-400-4396
  • Fax:
Mailing address:
  • Phone: 312-762-9999
  • Fax: 912-352-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333300000X
TaxonomyEmergency Response System Companies
License Number
License Number StateGA

VIII. Authorized Official

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