Healthcare Provider Details

I. General information

NPI: 1942701792
Provider Name (Legal Business Name): COASTAL ADDICTION RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2179 ASHLEY PHOSPHATE RD STE B
NORTH CHARLESTON SC
29406-4180
US

IV. Provider business mailing address

2179 ASHLEY PHOSPHATE RD STE B
NORTH CHARLESTON SC
29406-4180
US

V. Phone/Fax

Practice location:
  • Phone: 843-718-3168
  • Fax:
Mailing address:
  • Phone: 843-718-3168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JODI MOORE
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 864-303-2499