Healthcare Provider Details

I. General information

NPI: 1104814359
Provider Name (Legal Business Name): COASTAL FAMILY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10828 HIGHWAY 57
VANCLEAVE MS
39565-8264
US

IV. Provider business mailing address

10467 CORPORATE DR
GULFPORT MS
39503-4634
US

V. Phone/Fax

Practice location:
  • Phone: 228-826-4711
  • Fax: 228-374-0856
Mailing address:
  • Phone: 228-374-2494
  • Fax: 228-374-0856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. ANGELIQUE S GREER
Title or Position: CEO
Credential:
Phone: 228-374-2494