=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306862198
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERCOASTAL HEALTH CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2006
-----------------------------------------------------
Last Update Date | 04/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 E MARKET ST
-----------------------------------------------------
City | ROCKPORT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78382-2533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-729-0340
-----------------------------------------------------
Fax | 361-814-5305
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 414 S LIVE OAK ST
-----------------------------------------------------
City | LAMPASAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76550-2940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-556-8296
-----------------------------------------------------
Fax | 512-564-1100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. TIMOTHY SCOTT JULIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 512-556-8296
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 014456
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------