MEDICARE: COASTAL CAROLINA BEHAVIORAL HEALTHCARE, LLC

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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790113520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CAROLINA BEHAVIORAL HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	3806 PARK AVE STE A
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-6739
Country	:	US
Telephone Number	:	910-769-3575
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 HAY ST STE 303
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-5684
Country	:	US
Telephone Number	:	910-769-3575
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	LARONDA WOODS FREEMAN
Credential	:
Telephone Number	:	910-769-3575

Provider Enumeration Date	:	10/14/2013
Last Update Date	:	10/14/2013

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