Healthcare Provider Details

I. General information

NPI: 1366498297
Provider Name (Legal Business Name): COASTAL CAROLINA HEALTH CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 MEDICAL PARK AVE
NEW BERN NC
28562-5248
US

IV. Provider business mailing address

1040 MEDICAL PARK AVE
NEW BERN NC
28562-5248
US

V. Phone/Fax

Practice location:
  • Phone: 252-633-1678
  • Fax: 252-633-1403
Mailing address:
  • Phone: 252-633-1678
  • Fax: 252-633-1403

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: STEPHEN NUCKOLLS
Title or Position: CEO
Credential:
Phone: 252-514-6685