Healthcare Provider Details

I. General information

NPI: 1376582965
Provider Name (Legal Business Name): COASTAL CAROLINA HEALTH CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 MEDICAL PARK AVE
NEW BERN NC
28562-0000
US

IV. Provider business mailing address

1020 MEDICAL PARK AVE
NEW BERN NC
28562-5248
US

V. Phone/Fax

Practice location:
  • Phone: 252-634-2240
  • Fax: 252-634-2241
Mailing address:
  • Phone: 252-634-2240
  • Fax: 252-634-2241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

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