Basic Information
| Provider Information | |||||||||
| NPI: | 1760793343 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL HEARING CENTERS, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4868 | ||||||||
| Address2: | |||||||||
| City: | CALABASH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284671068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106715014 | ||||||||
| FaxNumber: | 9106080269 | ||||||||
| Practice Location | |||||||||
| Address1: | 2298 OCEAN HWY | ||||||||
| Address2: | |||||||||
| City: | SUPPLY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107552428 | ||||||||
| FaxNumber: | 9106080269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2010 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GORE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | EVANS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/AUDIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 9106715014 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | AU.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0700X | 1102 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech |
ID Information
| ID | Type | State | Issuer | Description | 3404235 | 05 | NC | MEDICAID |