Coastal Hospice Inc
Organization Active NPI Community Based Hospice Care Agency · Crescent City, CA
NPI 1407459308 · NPPES record last updated Jan 24, 2023
Key facts
- NPI
- 1407459308
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community Based Hospice Care Agency 251G00000X
- Legal business name
- COASTAL HOSPICE INC
- Practice address
- 786 H St
Crescent City, CA 95531-3748 - Phone
- (707) 460-6191
- Fax
- (866) 611-8843
- NPI assigned
- Nov 21, 2020
- Organization subpart
- Yes
- Parent organization (as reported)
- COASTAL HOME HEALTH & HOSPICE INC.
Authorized official
- Name
- Jamie Daugherty
- Title
- Ceo
- Phone
- (541) 512-5041
Owners & managing parties with NPI records 4
Corporate family (same tax ID) 4
Member of 1
Practitioners 2
-
Sally Beavers, RN
-
Laurent Edward Wanner, D.C.
Affiliated clinicians 2
-
Gudrun Reed, M.D.
Medicare Care Compare: Hospice
- Listed as
- Coastal Hospice, Inc
- Certified
- May 4, 2023
- Medicare certification status
- Active
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D2303478 | Coastal Hospice Inc | Certificate of waiver | Apr 24, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
Hospice certification: CCN B51786
- Legal name
- COASTAL HOSPICE INC
- Doing business as
- COASTAL HOME HEALTH & HOSPICE
- Certification status
- Active
- Provider type (POS)
- Hospice
- Participating since
- May 4, 2023
- Last certification
- Apr 20, 2023
- Organization structure
- Corporation · Non-profit
- Incorporated
- Dec 8, 2021 in CA
- Enrollment address
- 786 H St
Crescent City, CA 95531-3748
All disclosed owners & managing parties 8
| Name | Role | Since | Share |
|---|---|---|---|
| Veronica Spalding |
Corporate Officer |
Nov 17, 2022 | 16.67% |
| London Manor-Petersen |
Corporate Officer |
Nov 17, 2022 | 16.67% |
| Jamie Daugherty |
Corporate Director |
Nov 17, 2022 | 100% |
| W-2 Managing Employee |
Nov 17, 2022 | 100% | |
| Coastal Home Health & Hospice Inc |
5% Or Greater Direct Ownership Interest | Dec 8, 2021 | 100% |
| Cecelia Swick |
Corporate Officer |
Nov 17, 2022 | 16.67% |
| Roswitha Cimino |
Corporate Officer |
Nov 17, 2022 | 16.67% |
| Carlene Bettencourt |
Corporate Officer |
Nov 17, 2022 | 16.67% |
| Darlene Smith |
Corporate Officer |
Nov 17, 2022 | 16.67% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20230317001574 | CA | Part a Provider - Hospice | 6406220201 | Practice locations: Crescent City, CA |
National Provider Directory
- Tax ID family
- Coastal Home Health Hospic
- Part of
- Coastal Home Health Hospic
Locations
786 H St
Crescent City, CA 95531
Phone (541) 469-0405
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community Based Hospice Care Agency | 251G00000X | Yes |
Addresses
Primary practice location
786 H St
Crescent City, CA 95531-3748
Mailing address
PO Box 6042
Brookings, OR 97415-0137
Phone (707) 460-6191
Other providers in Crescent City, CA
- Jame3S J Cipolla
- Scott Thomas Clark
- Caryn Jean Cleland
- Perma Clendenin
- Coastal Cab Company LLC
- Mariah Elizabeth Coats
- Tracy David Cole
- Angela Dawn Collins
- Timothy John Connell
- Irene Contreras
All providers in Crescent City, CA · Community Based Hospice Care Agency in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 24, 2023. 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.