Basic Information
| Provider Information | |||||||||
| NPI: | 1558392209 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL HOME CARE SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHOICE HOME HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 TULLY RD | ||||||||
| Address2: | SUITE C-8A | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953500838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095248700 | ||||||||
| FaxNumber: | 2095248701 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 GARDEN CT | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939405367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316451400 | ||||||||
| FaxNumber: | 8316571996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 12/20/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | O'SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | VINCENT | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 2095248700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REHABFOCUS HOME HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | N | Agencies | Home Health | 251E00000X | 0700000367 | CA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | HHA574061G | 05 | CA | MEDICAID |