Coastal Family Health Center Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Leakesville, MS
NPI 1366515470 · NPPES record last updated Aug 16, 2024
Key facts
- NPI
- 1366515470
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- COASTAL FAMILY HEALTH CENTER INC
- Practice address
- 4336 High School Rd
Leakesville, MS 39451-2584 - Phone
- (601) 394-6830
- Fax
- (601) 394-6831
- NPI assigned
- Nov 16, 2006
- Organization subpart
- No
Authorized official
- Name
- Mrs. Angelique Greer
- Title
- Ceo
- Phone
- (228) 374-2494
Other NPIs on the same Medicare enrollment 37
Corporate family (same tax ID) 6
Practitioners 5
-
John C Adams, MD
-
Amy Malinda Lott, NURSE PRACTITIONER
-
Pooja Sharma, FNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MS
Federally qualified health center certification: CCN 251053
- Legal name
- COASTAL FAMILY HEALTH CENTER, INC
- Doing business as
- COASTAL FAMILY HEALTH CENTER INC - GREENE HIGH SCHOOL CLINIC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Aug 4, 2017
- Last certification
- Aug 4, 2017
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Jun 25, 1976 in MS
- Enrollment address
- 4336 High School Rd
Leakesville, MS 39451-2584
All disclosed owners & managing parties 13
| Name | Role | Since | Share |
|---|---|---|---|
| Judy a Grant |
Operational/Managerial Control |
Dec 31, 2016 | |
| Xuan Phan |
Corporate Director | Jan 1, 2021 | |
| Kwantrell D Green |
Operational/Managerial Control |
Dec 31, 2016 | |
| Roy a Tolbert |
Operational/Managerial Control |
Dec 31, 2016 | |
| Bertha J Oatis |
Operational/Managerial Control |
Dec 31, 2016 | |
| Paulette T Briscoe |
Operational/Managerial Control |
Dec 31, 2016 | |
| Christine M McLeod |
Operational/Managerial Control |
Dec 31, 2016 | |
| Angelique S Greer |
Corporate Director | Dec 31, 2016 | |
| W-2 Managing Employee | Dec 31, 2016 | ||
| Operational/Managerial Control |
Dec 31, 2016 | ||
| Xenia G Wickline |
Operational/Managerial Control |
Dec 31, 2016 | |
| Jane Campbell |
Corporate Director | Jan 1, 2021 | |
| Donna F Ramirez |
Operational/Managerial Control |
Dec 31, 2016 | |
| Shelby Ward |
Corporate Director | Jan 1, 2021 | |
| Joseph P Hudson |
Operational/Managerial Control |
Dec 31, 2016 |
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… |
| O20170804000900 | MS | Part a Provider - Federally Qualified Health Center (FQHC) | 8628989654 | Practice locations: Leakesville, MS |
National Provider Directory
- Tax ID family
- Coastal Family Health Center Inc
Locations
4336 High School Rd
Leakesville, MS 39451
Phone (601) 394-4660
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
4336 High School Rd
Leakesville, MS 39451-2584
Mailing address
10467 Corporate Dr
Gulfport, MS 39503-4634
Phone (228) 374-2494
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 06887066 | Medicaid | MS |
Other names
- Coastal Family Health Center, Inc - Green High School Clinic
Other providers in Leakesville, MS
- Sherrill Hope Backstrom
- Bethany Ballenger
- Madison Bohannon
- Jason S. Box
- Choice Primary Healthcare PLLC
- Coastal Family Health Center Inc
- Coastal Family Health Center Inc
- Coastal Family Health Center, Inc
- Coastal Family Health Center, Inc
- Contona Collins
All providers in Leakesville, 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.