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Coastal Community Health Services, Inc.

Organization Active NPI Federally Qualified Health Center (FQHC) · Woodbine, GA

NPI 1225808199 · NPPES record last updated Jan 3, 2024

Key facts

NPI
1225808199
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
COASTAL COMMUNITY HEALTH SERVICES, INC.
Practice address
308 Bedell Ave
Woodbine, GA 31569-2091
Phone
(912) 275-8028
NPI assigned
Jan 3, 2024
Organization subpart
No

Authorized official

Name
Kavanaugh Chandler, MD
Title
Ceo
Phone
(912) 275-8028

Other NPIs with the same Medicare PAC ID 16

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Corporate family (same tax ID) 23

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners 54

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 54

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D2295303Coastal Community Health - Woodbine Clinic
308 Bedell Avenue, Woodbine, GA 31569		Provider-performed microscopyDec 7, 2027

Medicare participation

Medicare fee-for-service enrollment
Enrolled in GA

Federally qualified health center certification: CCN C21009

Legal name
COASTAL COMMUNITY HEALTH SERVICES INC
Doing business as
COASTAL COMMUNITY HEALTH-WOODBINE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 12, 2024
Last certification
Jun 12, 2024
Ownership / control type
For profit – corporation
Organization structure
Corporation · Non-profit
Incorporated
Oct 25, 2012 in GA
Enrollment address
308 Bedell Ave
Woodbine, GA 31569-2091

All disclosed owners & managing parties 6

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Faye Mathis
Individual 		Corporate Director
Board Vice Chair		 Jan 9, 2020
Kavanaugh Chandler
Individual 		Corporate Director
Ceo		 Jul 1, 2021 100%
W-2 Managing Employee
Ceo		 Jul 6, 2021 100%
Jeffery Clark
Individual 		Corporate Director
Board Treasurer		 Aug 17, 2022
Samantha Young
Individual 		Corporate Director
Board Member		 Jun 26, 2023
Josiah Watts
Individual 		Corporate Director
Board Chair		 Aug 30, 2022
D'Jon McNair
Individual 		Corporate Director
Board Member		 Jun 26, 2023

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20240612001356 GA Part a Provider - Federally Qualified Health Center (FQHC) 0345463683 Practice locations: Woodbine, GA

National Provider Directory

Tax ID family
Coastal HLTH Srvcs Inc (24 organizations share this tax ID)

Locations

10055 Ford Ave
Ste 4A
Richmond Hill, GA 31324
Phone (912) 527-5352

21300 Highway 82
Waynesville, GA 31566

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Yes

Addresses

Primary practice location

308 Bedell Ave
Woodbine, GA 31569-2091

Mailing address

100 Professional Center Dr
Brunswick, GA 31525-6743
Phone (912) 275-8028

Other names

  • Coastal Community Health - Woodbine Doing business as

Other providers in Woodbine, GA

All providers in Woodbine, GA · Federally Qualified Health Center (FQHC) in Georgia

Sources for this page

Verify at the official NPI Registry.