Basic Information
| Provider Information | |||||||||
| NPI: | 1861161044 | ||||||||
| 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: | 805 S MADISON ST | ||||||||
| Address2: | |||||||||
| City: | WHITEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284724613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106632273 | ||||||||
| FaxNumber: | 9106634050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2021 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | ALECIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9106632273 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COASTAL COMPREHENSIVE CARE PA | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207LP2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.