Coastal Family Health Center, Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Bay St Louis, MS
NPI 1124016209 · NPPES record last updated Aug 16, 2024
Key facts
- NPI
- 1124016209
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- COASTAL FAMILY HEALTH CENTER, INC
- Practice address
- 109 Hospital Dr
Bay St Louis, MS 39520-1604 - Phone
- (228) 463-9666
- 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 37
Corporate family (same tax ID) 16
Practitioners 1
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 25D0948437 | Coastal Family Health Center-Bay St Louis | Provider-performed microscopy | Jun 8, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MS
Federally qualified health center certification: CCN 251866
- Legal name
- COASTAL FAMILY HEALTH CENTER, INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Jul 15, 1998
- Last certification
- Jul 15, 1998
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Aug 25, 1978 in MS
- Enrollment address
- 109 Hospital Dr
Bay St Louis, MS 39520-1604
All disclosed owners & managing parties 13
| Name | Role | Since | Share |
|---|---|---|---|
| Judy a Grant |
Corporate Director |
Jun 1, 2013 | |
| Xuan Phan |
Corporate Director | Jan 1, 2021 | |
| Kwantrell D Green |
Corporate Director |
Jun 1, 2009 | |
| Roy a Tolbert |
Corporate Director |
Jun 1, 2012 | |
| Bertha J Oatis |
Corporate Director |
Jun 1, 2009 | |
| Paulette T Briscoe |
Corporate Director |
Jun 1, 2009 | |
| Christine M McLeod |
Corporate Director | Jan 1, 2021 | |
| Angelique S Greer |
Corporate Officer |
Aug 1, 2010 | |
| W-2 Managing Employee | Aug 1, 2010 | ||
| Xenia G Wickline |
Corporate Director | Jan 1, 2021 | |
| Jane Campbell |
Corporate Director | Jan 1, 2021 | |
| Shelby Ward |
Corporate Director | Jan 1, 2021 | |
| Shirley Leist |
Corporate Director | Nov 1, 2021 | |
| Joseph P Hudson |
Corporate Director |
Jun 1, 2011 |
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 |
|---|---|---|---|---|
| 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… |
| O20081002000153 | MS | Part a Provider - Federally Qualified Health Center (FQHC) | 8628989654 | Practice locations: Bay St Louis, MS |
National Provider Directory
- Tax ID family
- Coastal Family Health Center
Locations
109 Hospital Dr
Bay St Louis, MS 39520
Phone (228) 463-9666
7070 Stennis Airport Rd
Kiln, MS 39556
Phone (228) 463-2669
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | MS | Yes |
Addresses
Primary practice location
109 Hospital Dr
Bay St Louis, MS 39520-1604
Mailing address
10467 Corporate Dr
Gulfport, MS 39503-4634
Phone (228) 374-2494
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| C00895 | Other | MS | MEDICARE/CAHABA |
| 9014820 | Medicaid | MS |
Other names
- Coastal Family Health Center
Other providers in Bay St Louis, MS
- Robert Michael Chapmon
- Bertin C Chevis
- Karen Chevis
- Sidney Albert Chevis
- Children'S International, LLC
- Coastal Family Health Center, Inc
- Coastal Family Health Center, Inc
- Coastal Family Health Center, Inc
- Coastal Family Health Center, Inc
- Coastal Family Health Center, Inc.
All providers in Bay St Louis, 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.