Healthcare Provider Details

I. General information

NPI: 1346730173
Provider Name (Legal Business Name): COASTAL FOOT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 04/03/2024
Certification Date: 03/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 OFFICE PARK DRIVE SUITE B
JACKSONVILLE NC
28546-3219
US

IV. Provider business mailing address

29 OFFICE PARK DRIVE SUITE B
JACKSONVILLE NC
28546-3219
US

V. Phone/Fax

Practice location:
  • Phone: 910-938-6000
  • Fax: 910-938-3618
Mailing address:
  • Phone: 910-938-6000
  • Fax: 910-938-3618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: VALENTINE HAMILTON
Title or Position: OWNER/PHYSICIAN
Credential: D.P.M.
Phone: 910-938-6000