Basic Information
| Provider Information | |||||||||
| NPI: | 1467691238 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL HORIZONS CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284126431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103430145 | ||||||||
| FaxNumber: | 9103415779 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 COASTAL HORIZONS DR | ||||||||
| Address2: | |||||||||
| City: | SHALLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107544515 | ||||||||
| FaxNumber: | 9107547997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2009 | ||||||||
| LastUpdateDate: | 07/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | WELLER-STARGELL | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9103430145 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COASTAL HORIZONS CENTER, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 5911555 | 05 | NC | MEDICAID | 5908303 | 05 | NC | MEDICAID |