Healthcare Provider Details

I. General information

NPI: 1437311248
Provider Name (Legal Business Name): COASTAL CHILDRENS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 JENKINS AVENUE
MAYSVILLE NC
28555
US

IV. Provider business mailing address

703 NEWMAN RD
NEW BERN NC
28562-5239
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