Healthcare Provider Details

I. General information

NPI: 1457805467
Provider Name (Legal Business Name): COASTAL COMMUNITY BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5155 GA HIGHWAY 40 E
SAINT MARYS GA
31558-9410
US

IV. Provider business mailing address

5155 GA HIGHWAY 40 E
SAINT MARYS GA
31558-9410
US

V. Phone/Fax

Practice location:
  • Phone: 912-434-1794
  • Fax: 912-662-8785
Mailing address:
  • Phone: 912-434-1794
  • Fax: 912-662-8785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number74308
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN HAIGLER
Title or Position: ADMINISTRATION
Credential:
Phone: 912-434-1794