NPIMap

Organization Active NPI

Coastal Community Health Services, Inc.

  • Federally Qualified Health Center (FQHC)
  • Darien, GA
National Provider Identifier
1235834045
Registry record updated Apr 3, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
COASTAL COMMUNITY HEALTH SERVICES, INC.
Practice address
1022 Miller LN SW
Darien, GA 31305-3738
Phone
(912) 342-7846
NPI assigned
Apr 3, 2023
Last updated
Apr 3, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 3, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

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

Specialties & licenses 1

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

Addresses

Primary practice location

1022 Miller LN SW
Darien, GA 31305-3738

Mailing address

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230731002962 GA Part A Provider - Federally Qualified Health Center (FQHC) 0345463683 Practice locations: Darien, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1235834045. Details of each certification follow.

Federally qualified health center certification: CCN 851015

Legal name
COASTAL COMMUNITY HEALTH SERVICES INC
Doing business as
COASTAL COMMUNITY HEALTH - DARIEN
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 5, 2023
Last certification
Apr 5, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 25, 2012 in GA
Enrollment address
1022 Miller LN SW
Darien, GA 31305-3738

Other NPIs with the same Medicare PAC ID 16

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

View all 16

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D2276282Coastal Community Health-Darien1022 Miller Lane SW, Darien, GA 31305Certificate of waiverFeb 6, 2027

National Provider Directory

National Provider Directory
Tax ID family
Coastal HLTH Srvcs Inc24 organizations share this tax ID, including this one

Other organizations with this tax ID 23

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

View all 23

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Jennifer Duvall Individual Corporate DirectorBoard Secretary Dec 24, 2019
Faye Mathis Individual Corporate DirectorBoard Member Jan 9, 2020
Esther Figueroa Individual Corporate DirectorBoard Member Mar 7, 2017
Kavanaugh Chandler Individual Corporate OfficerCeo Jul 6, 2021 100%
W-2 Managing EmployeeCeo Jul 6, 2021 100%
Greg Jaudon Individual Corporate DirectorBoard Treasurer Jul 21, 2015
Margaret R Tuten Individual Corporate DirectorBoard Member Oct 16, 2014
Stephanie Krause-Jones Individual Corporate DirectorBoard Member May 22, 2014
George Stevens Individual Corporate DirectorBoard Member May 23, 2016
Josiah Watts Individual Corporate DirectorBoard Chair Aug 30, 2022
John Laws Individual Corporate DirectorBoard Vice Chair Apr 8, 2015
Pamela Rogers Individual Corporate DirectorBoard Member May 22, 2014

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1680480000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1680480000000",
    "number": "1235834045",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 PROFESSIONAL CENTER DR",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "315256743",
            "telephone_number": "912-275-8028"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1022 MILLER LN SW",
            "city": "DARIEN",
            "state": "GA",
            "postal_code": "313053738",
            "telephone_number": "912-342-7846"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COASTAL COMMUNITY HEALTH SERVICES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-04-03",
        "last_updated": "2023-04-03",
        "certification_date": "2023-04-01",
        "status": "A",
        "authorized_official_last_name": "CHANDLER",
        "authorized_official_first_name": "KAVANAUGH",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "912-275-8028",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Darien, GA

Sources for this page

Verify at the official NPI Registry.