MEDICARE: COASTAL FAMILY HEALTH CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1548927163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL FAMILY HEALTH CENTER, INC

Provider Business Mailing Address
First Line	:	10467 CORPORATE DR
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39503-4634
Country	:	US
Telephone Number	:	228-374-2494
Fax Number	:

Provider Business Practice Location Address
First Line	:	5404 HURLEY WADE RD
Second Line	:
City	:	MOSS POINT
State	:	MS
Zip	:	39562-2500
Country	:	US
Telephone Number	:	228-374-2494
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ANGELIQUE GREER
Credential	:
Telephone Number	:	228-374-2494

Provider Enumeration Date	:	11/18/2021
Last Update Date	:	08/16/2024

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