Healthcare Provider Details

I. General information

NPI: 1073911822
Provider Name (Legal Business Name): COASTAL CAROLINA HEALTH CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2014
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LATHAN LN
NEW BERN NC
28562-4002
US

IV. Provider business mailing address

PO BOX 12248
NEW BERN NC
28561-2248
US

V. Phone/Fax

Practice location:
  • Phone: 252-672-0224
  • Fax:
Mailing address:
  • Phone: 252-672-0224
  • Fax: 252-672-0227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

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