Provider Demographics
NPI:1730681388
Name:COASTLINE THERAPY GROUP, LLC
Entity type:Organization
Organization Name:COASTLINE THERAPY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:BAGEANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-461-9168
Mailing Address - Street 1:1468 EASTBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-8431
Mailing Address - Country:US
Mailing Address - Phone:910-461-9168
Mailing Address - Fax:
Practice Address - Street 1:3901 WRIGHTSVILLE AVE STE 120
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6256
Practice Address - Country:US
Practice Address - Phone:910-679-8385
Practice Address - Fax:910-679-8387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 2251P0200X, 225X00000X, 235Z00000X
NC10745225X00000X
NC12318235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty