Healthcare Provider Details

I. General information

NPI: 1457828253
Provider Name (Legal Business Name): COASTAL COMPREHENSIVE CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 SUNSET BLVD N STE A
SUNSET BEACH NC
28468-4340
US

IV. Provider business mailing address

PO BOX 2123
BRYSON CITY NC
28713-5123
US

V. Phone/Fax

Practice location:
  • Phone: 910-663-2273
  • Fax: 910-663-4050
Mailing address:
  • Phone: 910-490-0490
  • Fax: 828-538-4441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TERRESA A LONG
Title or Position: PRESIDENT
Credential: NP
Phone: 910-663-2273