NPIMap

Organization Active NPI

Coastal Care Inc

  • Primary Care Clinic/Center
  • Waycross, GA
National Provider Identifier
1538367149
Registry record updated Jul 1, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
License
055345 Issued in GA
Legal business name
COASTAL CARE INC
Practice address
1405 Alice St
Waycross, GA 31501-4528
Phone
(912) 285-8822
Fax
(912) 490-4870
NPI assigned
Jul 5, 2007
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Dr. Warren S Theis, MDNPI 1588658702
Title
Owner
Phone
(912) 285-8822

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Practitioners 34

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

View all 34

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041115000734 GA Part B Supplier - Clinic/Group Practice 8921062498 Receives reassigned benefits from 2 practitioners
Practice locations: Waycross, GA

National Provider Directory

National Provider Directory

Locations

2005 Pioneer St
Ste B
Waycross, GA 31501
Phone (912) 285-8822

Specialties & licenses 2

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 055345 GA
Primary Care Clinic/Center 261QP2300X 055345 GA Primary

Addresses

NPPES NPI Registry

Primary practice location

1405 Alice St
Waycross, GA 31501-4528

Mailing address

1405 Alice St
Waycross, GA 31501-4528
Phone (912) 285-8822

Other identifiers 1

NPPES NPI Registry
IdentifierTypeStateIssuer
672694005AMedicaidGA

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Jul 1, 2024.

{
    "created_epoch": "1183593600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1719792000000",
    "number": "1538367149",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1405 ALICE ST",
            "city": "WAYCROSS",
            "state": "GA",
            "postal_code": "315014528",
            "telephone_number": "912-285-8822",
            "fax_number": "912-490-4870"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1405 ALICE ST",
            "city": "WAYCROSS",
            "state": "GA",
            "postal_code": "315014528",
            "telephone_number": "912-285-8822",
            "fax_number": "912-490-4870"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COASTAL CARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-07-05",
        "last_updated": "2024-07-01",
        "status": "A",
        "authorized_official_last_name": "THEIS",
        "authorized_official_first_name": "WARREN",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "912-285-8822",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "GA",
            "license": "055345",
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "GA",
            "license": "055345",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "672694005A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Waycross, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.