Healthcare Provider Details

I. General information

NPI: 1962665653
Provider Name (Legal Business Name): COASTAL CHILDRENS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 STONE BRIDGE SQUARE
HAVELOCK NC
28532
US

IV. Provider business mailing address

218 STONEBRIDGE SQ
HAVELOCK NC
28532-9505
US

V. Phone/Fax

Practice location:
  • Phone: 252-633-2900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANE HOUCK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 252-633-2900