Healthcare Provider Details

I. General information

NPI: 1093868309
Provider Name (Legal Business Name): COASTAL CAROLINA RESPIRATORY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S. BROWN ROAD
BEULAVILLE NC
28518-0467
US

IV. Provider business mailing address

106 S. BROWN ROAD PO BOX 467
BEULAVILLE NC
28518-0467
US

V. Phone/Fax

Practice location:
  • Phone: 919-920-8916
  • Fax:
Mailing address:
  • Phone: 919-920-8916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberA407
License Number StateNC

VIII. Authorized Official

Name: MS. LISA KELLY PICKETT
Title or Position: PRESIDENT OWNER
Credential: RRT, RCP, AE-C
Phone: 919-920-8916