Coastal Family Health Center, Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Vancleave, MS
NPI 1104814359 · NPPES record last updated Aug 16, 2024
Key facts
- NPI
- 1104814359
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- COASTAL FAMILY HEALTH CENTER, INC
- Practice address
- 10828 Highway 57
Vancleave, MS 39565-8264 - Phone
- (228) 826-4711
- Fax
- (228) 374-0856
- NPI assigned
- Oct 12, 2005
- Organization subpart
- No
Authorized official
- Name
- Mr. Angelique S Greer
- Title
- Ceo
- Phone
- (228) 374-2494
Other NPIs on the same Medicare enrollment 38
Corporate family (same tax ID) 15
Related certifications (CCN) 3
Practitioners 3
-
Christy Michelle Howard, CPNP
-
Hoyt Aaron Williamson, FNP-BC
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MS
Federally qualified health center certification: CCN 251924
- Legal name
- COASTAL FAMILY HEALTH CENTER, INC
- Doing business as
- COASTAL FAMILY HEALTH CENTER, INC - VANCLEAVE
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jan 15, 2004
- Last certification
- Jan 15, 2004
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Aug 25, 1978 in MS
- Enrollment address
- 10828 Highway 57
Vancleave, MS 39565-8264 - Related CCNs
- 251811
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Judy a Grant |
Corporate Director |
May 21, 2014 | |
| Xuan Phan |
Corporate Director | Jan 1, 2021 | |
| Kwantrell D Green |
Corporate Director |
May 21, 2014 | |
| Roy a Tolbert |
Corporate Director |
May 21, 2014 | |
| Bertha J Oatis |
Corporate Director |
May 21, 2014 | |
| Paulette T Briscoe |
Corporate Director |
May 21, 2014 | |
| Christine M McLeod |
Corporate Director |
May 21, 2014 | |
| Angelique S Greer |
Corporate Officer |
May 21, 2014 | |
| W-2 Managing Employee |
May 21, 2014 | ||
| Xenia G Wickline |
Corporate Director |
Mar 6, 2019 | |
| Jane Campbell |
Corporate Director |
Mar 6, 2019 | |
| Shelby Ward |
Corporate Director |
Mar 6, 2019 | |
| Joseph P Hudson |
Corporate Director |
May 21, 2014 |
All facility ownership & control disclosures 6
| Facility | Type | Role | Since |
|---|---|---|---|
| Coastal Family Health Center, Inc - North Bay Elementary School Clinic |
Federally qualified health center | Operational/Managerial Control | Nov 1, 2021 |
| Coastal Family Health Center, Inc - Bay High School Clinic |
Federally qualified health center | Operational/Managerial Control | Nov 1, 2021 |
| Coastal Family Health Center Inc - Waveland Elementary School Clinic |
Federally qualified health center | Operational/Managerial Control | Nov 1, 2021 |
| Coastal Family Health Center Inc - East Central Upper Elementary Schoo |
Federally qualified health center | Operational/Managerial Control | Nov 1, 2021 |
| Coastal Family Health Center Inc - Bay Waveland Middle School |
Federally qualified health center | Operational/Managerial Control (100%) | Feb 9, 2022 |
| Coastal Family Health Center, Inc-Vancleave Upper Elementary Clinic |
Federally qualified health center | Operational/Managerial Control | Nov 1, 2021 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20030924000019 | MS | Part a Provider - Federally Qualified Health Center (FQHC) | 8628989654 |
1 other NPI on this enrollment Practice locations: Vancleave, MS |
| O20040108000698 | MS | Part B Supplier - Clinic/Group Practice | 8628989654 |
Receives reassigned benefits from 90 practitioners 37 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: MC Lain, MS; Moss Point, MS; Ocean Springs, MS; Pass Christian, MS; Richton, MS; State Line, MS; Vancleave, MS; Waveland, MS… |
National Provider Directory
- Tax ID family
- Coastal Family Health Center
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
10828 Highway 57
Vancleave, MS 39565-8264
Mailing address
10467 Corporate Dr
Gulfport, MS 39503-4634
Phone (228) 374-2494
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 9011503 | Medicaid | MS | |
| C00895 | Other | MS | MEDICARE |
Other names
- Coastal Family Health Center
Other providers in Vancleave, MS
- Leigh Chiasson
- Karley Clark
- Coast Nurse Practitioners, Inc
- Coast Nurse Practitioners, Inc.
- Coastal Family Health Center
- Coastal Family Health Center, Inc
- Coastal Family Health Center, Inc
- Cohen Podiatry Clinics
- Kelly Marcus Coleman
- Coletha Deshay Colley
All providers in Vancleave, MS · Federally Qualified Health Center (FQHC) in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 16, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.