Healthcare Provider Details

I. General information

NPI: 1811325392
Provider Name (Legal Business Name): COASTAL COMMUNITY CARE SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2013
Last Update Date: 10/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4615 NORTH FWY STE 204
HOUSTON TX
77022-2920
US

IV. Provider business mailing address

4615 NORTH FWY STE 204
HOUSTON TX
77022-2920
US

V. Phone/Fax

Practice location:
  • Phone: 713-694-0051
  • Fax: 713-694-4711
Mailing address:
  • Phone: 713-694-0051
  • Fax: 713-694-4711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number001008928
License Number StateTX

VIII. Authorized Official

Name: MR. HYACINTH M CHIEDU
Title or Position: DIRECTOR
Credential:
Phone: 713-694-0051