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General NPI Number Information
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NPI Number | 1033776919
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Entity Type | Organization
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Legal Business Name | SOUTH COAST HOME LLC
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Dates
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Enumeration Date | 05/25/2019
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Last Update Date | 02/26/2024
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Provider Practice Location Address
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Address Line | 72633 M 43
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City | SOUTH HAVEN
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State | MI
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Zip | 49090-8734
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Country | US
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Telephone | 269-998-9349
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 29
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City | MACATAWA
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State | MI
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Zip | 49434-0029
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LICENSEE/OWNER
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Name | MR. CHESTER KWIATKOWSKI
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Credential |
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Telephone | 269-998-9349
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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