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General NPI Number Information
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NPI Number | 1538367149
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Entity Type | Organization
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Legal Business Name | COASTAL CARE INC
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Dates
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Enumeration Date | 07/05/2007
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Last Update Date | 07/01/2024
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Provider Practice Location Address
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Address Line | 1405 ALICE ST
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City | WAYCROSS
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State | GA
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Zip | 31501-4528
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Country | US
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Telephone | 912-285-8822
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Fax | 912-490-4870
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Provider Business Mailing Address
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Address Line | 1405 ALICE ST
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City | WAYCROSS
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State | GA
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Zip | 31501-4528
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Country | US
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Telephone | 912-285-8822
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Fax | 912-490-4870
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Authorized Official
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Title or Position | OWNER
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Name | DR. WARREN S THEIS
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Credential | MD
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Telephone | 912-285-8822
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 055345
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 055345
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License Number State | GA
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