NPIMap

Organization Active NPI

Coastal Community Health Services, Inc.

  • Federally Qualified Health Center (FQHC)
  • Fernandina Beach, FL
National Provider Identifier
1851131874
Registry record updated May 28, 2024
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
22385 Flora Park Crossing Drive
Fernandina Beach, FL 32034
Phone
(904) 404-8641
Fax
(904) 227-3246
NPI assigned
May 28, 2024
Last updated
May 28, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 28, 2024

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 Primary

Addresses

Primary practice location

22385 Flora Park Crossing Drive
Fernandina Beach, FL 32034

Mailing address

100 Professional Center Dr
Brunswick, GA 31525-6743
Phone (912) 574-5075

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20241112000857 FL Part B Supplier - Clinic/Group Practice 0345463683 Receives reassigned benefits from 95 practitioners
Practice locations: Fernandina Beach, FL
O20241120002398 FL Part A Provider - Federally Qualified Health Center (FQHC) 0345463683 Practice locations: Fernandina Beach, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1851131874. Details of each certification follow.

Federally qualified health center certification: CCN C11043

Legal name
COASTAL COMMUNITY HEALTH SERVICES INC
Doing business as
COASTAL COMMUNITY HEALTH - FERNANDINA/YULEE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 20, 2024
Last certification
Nov 20, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
22385 Flora Parke Xing
Fernandina Beach, FL 32034-8000

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
10D2309865Coastal Community Health Services Inc22385 Flora Park Crossing Dr, Fernandina Beach, FL 32034Provider-performed microscopyAug 21, 2026

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 6

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

NameRoleSinceShare
Faye Mathis Individual Corporate DirectorBoard Vice Chair Jan 9, 2020
Kavanaugh Chandler Individual Corporate DirectorCeo Jul 1, 2021 100%
W-2 Managing EmployeeCeo Jul 6, 2021 100%
Jeffery Clark Individual Corporate DirectorBoard Treasurer Aug 17, 2022
Samantha Young Individual Corporate DirectorBoard Member Jun 26, 2023
Josiah Watts Individual Corporate DirectorBoard Chair Aug 30, 2022
D'Jon McNair Individual Corporate DirectorBoard Member Jun 26, 2023

Practitioners & affiliated clinicians

Practitioners 98

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.

View all 98

NPI Registry JSON

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

{
    "created_epoch": "1716854400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1716854400000",
    "number": "1851131874",
    "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": "912-574-5075"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "22385 FLORA PARK CROSSING DRIVE",
            "city": "FERNANDINA BEACH",
            "state": "FL",
            "postal_code": "32034",
            "telephone_number": "904-404-8641",
            "fax_number": "904-227-3246"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COASTAL COMMUNITY HEALTH SERVICES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-05-28",
        "last_updated": "2024-05-28",
        "certification_date": "2024-05-22",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fernandina Beach, FL

Sources for this page

Verify at the official NPI Registry.