Healthcare Provider Details

I. General information

NPI: 1780792705
Provider Name (Legal Business Name): COASTAL RESIDENTIAL SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 WESTERN BLVD STE T
JACKSONVILLE NC
28546-6852
US

IV. Provider business mailing address

PO BOX 7128
JACKSONVILLE NC
28540-2128
US

V. Phone/Fax

Practice location:
  • Phone: 910-938-9550
  • Fax: 910-346-9186
Mailing address:
  • Phone: 910-938-9550
  • Fax: 910-346-9186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHL-067-085
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHL-067-052
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHL-067-049
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHL-067-059
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHL-067-091
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL-067-052
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL-067049
License Number StateNC
# 8
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL-067-059
License Number StateNC
# 9
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL-067-091
License Number StateNC

VIII. Authorized Official

Name: CAROL WILSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 910-938-9550