Healthcare Provider Details

I. General information

NPI: 1235126830
Provider Name (Legal Business Name): COASTAL PEDIATRIC CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 N 35TH ST
MOREHEAD CITY NC
28557-3104
US

IV. Provider business mailing address

212 N 35TH ST
MOREHEAD CITY NC
28557-3104
US

V. Phone/Fax

Practice location:
  • Phone: 252-247-5212
  • Fax: 252-247-1034
Mailing address:
  • Phone: 252-247-5212
  • Fax: 252-247-1034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNC

VIII. Authorized Official

Name: MRS. BETTY W WALLACE
Title or Position: OWNER
Credential: RN, MSN, PNP
Phone: 252-247-5212