Healthcare Provider Details

I. General information

NPI: 1821186081
Provider Name (Legal Business Name): CAROLINA SHORES HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9869 OCEAN HWY W STE 10
CALABASH NC
28467-2636
US

IV. Provider business mailing address

9869 OCEAN HWY W STE 10
CALABASH NC
28467-2636
US

V. Phone/Fax

Practice location:
  • Phone: 910-575-0281
  • Fax: 910-575-0282
Mailing address:
  • Phone: 910-575-0281
  • Fax: 910-575-0282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20979
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201481
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number005002515
License Number StateNC

VIII. Authorized Official

Name: MRS. ANDREA S NANCE
Title or Position: PRESIDENT
Credential: FNP-C
Phone: 910-575-0281