Healthcare Provider Details

I. General information

NPI: 1760027874
Provider Name (Legal Business Name): COASTAL CAROLINA CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 01/23/2024
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15441 US HIGHWAY 17 N STE 501
HAMPSTEAD NC
28443-0016
US

IV. Provider business mailing address

831 WINE CELLAR CIR
WILMINGTON NC
28411-9298
US

V. Phone/Fax

Practice location:
  • Phone: 910-512-2520
  • Fax: 910-900-8002
Mailing address:
  • Phone: 910-512-2520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL THOMAS
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 910-685-7307