Healthcare Provider Details

I. General information

NPI: 1841317963
Provider Name (Legal Business Name): COASTAL REHABILITATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532C CARATOKE HIGHWAY
MOYOCK NC
27958
US

IV. Provider business mailing address

101 MEDICAL DRIVE
ELIZABETH CITY NC
27909-3361
US

V. Phone/Fax

Practice location:
  • Phone: 252-435-6046
  • Fax: 252-435-6210
Mailing address:
  • Phone: 252-338-2114
  • Fax: 252-338-2115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7200037
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier7700350
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 3
Identifier0002W
Identifier TypeOTHER
Identifier State
Identifier IssuerBCBS FACILITY
# 4
Identifier07763
Identifier TypeOTHER
Identifier State
Identifier IssuerBCBS

VIII. Authorized Official

Name: MR. JUSTYN J YAGER
Title or Position: OWNER
Credential: DPT
Phone: 252-338-2114