NPIMap

Organization Active NPI

Coastal Community Health Services, Inc.

  • Federally Qualified Health Center (FQHC)
  • Townsend, GA
National Provider Identifier
1417663147
Registry record updated Jan 26, 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
1299 Ga Highway 57
Townsend, GA 31331-8128
Phone
(912) 574-5277
Fax
(912) 549-1040
NPI assigned
Jan 26, 2023
Last updated
Jan 26, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 26, 2023

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

Authorized official

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

Specialties & licenses 1

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

Addresses

Primary practice location

1299 Ga Highway 57
Townsend, GA 31331-8128

Mailing address

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

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL eClinicalWorks Direct

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220607003401 GA Part A Provider - Federally Qualified Health Center (FQHC) 0345463683 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Townsend, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1417663147. Details of each certification follow.

Federally qualified health center certification: CCN 851171

Legal name
COASTAL COMMUNITY HEALTH SERVICES INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 23, 2022
Last certification
May 23, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 25, 2012 in GA
Enrollment address
1299 Ga Highway 57
Townsend, GA 31331-8128

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

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 13

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
Honey Sparre Individual Corporate DirectorBoard Member Dec 27, 2019
Esther Figueroa Individual Corporate DirectorBoard Member Mar 7, 2017
Lynn Ventimiglia-Lobit Individual Corporate DirectorBoard Member Jan 24, 2021
Adam Brown Individual Corporate DirectorBoard Chair Jul 1, 2019
Kavanaugh Chandler Individual Corporate DirectorCeo 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
John Laws Individual Corporate DirectorBoard Vice Chair Apr 8, 2015
Pamela Rogers Individual Corporate DirectorBoard Member May 22, 2014

Practitioners & affiliated clinicians

Practitioners 6

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": "1674691200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674691200000",
    "number": "1417663147",
    "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": "1299 GA HIGHWAY 57",
            "city": "TOWNSEND",
            "state": "GA",
            "postal_code": "313318128",
            "telephone_number": "912-574-5277",
            "fax_number": "912-549-1040"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COASTAL COMMUNITY HEALTH SERVICES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-01-26",
        "last_updated": "2023-01-26",
        "certification_date": "2023-01-19",
        "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"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "eClinicalWorks",
            "affiliation": "N",
            "endpointDescription": "EMR",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "HTTPS",
            "address_1": "1299 Ga Highway 57",
            "city": "Townsend",
            "state": "GA",
            "country_code": "US",
            "postal_code": "313318128",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Townsend, GA

Sources for this page

Verify at the official NPI Registry.