=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124288501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL FAMILY HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2008
-----------------------------------------------------
Last Update Date | 06/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15024 MARTIN LUTHER KING JR BLVD
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39501-8306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-863-9781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1046 DIVISION ST
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39530-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-374-2494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOE DAWSEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 228-374-2494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------