Basic Information
| Provider Information | |||||||||
| NPI: | 1659621985 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL HEARING CENTERS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 4868 | ||||||||
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| City: | CALABASH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106715014 | ||||||||
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| Practice Location | |||||||||
| Address1: | 584 FARRINGDOM ST | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283582615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106715014 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2012 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | GORE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | EVANS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9106715014 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | AU.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0700X | 1102 | Y | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech |
ID Information
| ID | Type | State | Issuer | Description | 3404235 | 05 | NC | MEDICAID |