Healthcare Provider Details

I. General information

NPI: 1295745453
Provider Name (Legal Business Name): COASTAL COMMUNITY RETIREMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 MARSHSEDGE LANE
ST. SIMONS ISLAND GA
31522
US

IV. Provider business mailing address

136 MARSHSEDGE LANE
ST. SIMONS ISLAND GA
31522
US

V. Phone/Fax

Practice location:
  • Phone: 912-291-2001
  • Fax:
Mailing address:
  • Phone: 912-291-2001
  • Fax: 912-291-2098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT B REES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 912-291-2004