Basic Information
| Provider Information | |||||||||
| NPI: | 1457828253 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL COMPREHENSIVE CARE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 SUNSET BLVD N STE A | ||||||||
| Address2: | |||||||||
| City: | SUNSET BEACH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284684340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106632273 | ||||||||
| FaxNumber: | 9106634050 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 SUNSET BLVD N STE A | ||||||||
| Address2: | |||||||||
| City: | SUNSET BEACH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284684340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106632273 | ||||||||
| FaxNumber: | 9106634050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2018 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | TERRESA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9106632273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LA0401X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Addiction Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207LP2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1932413747 | 05 | NC | MEDICAID |