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General NPI Number Information
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NPI Number | 1164647277
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Entity Type | Organization
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Legal Business Name | COASTAL HAVEN HOME
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Dates
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Enumeration Date | 04/16/2007
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Last Update Date | 06/27/2008
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Provider Practice Location Address
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Address Line | 399 DOE RUN DR.
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City | SUPPLY
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State | NC
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Zip | 28462-6349
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Country | US
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Telephone | 910-846-9196
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Fax |
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Provider Business Mailing Address
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Address Line | 1290 WINDY RIDGE TRL SW P.O.OX 721
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City | SUPPLY
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State | NC
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Zip | 28462-3215
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Country | US
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Telephone | 910-846-9196
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. WANDA DENISE WILSON
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Credential |
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Telephone | 910-846-9196
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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