Healthcare Provider Details

I. General information

NPI: 1053103796
Provider Name (Legal Business Name): BEACH PRIMARY CARE AND WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

863 OCEAN HWY W
SUPPLY NC
28462-4059
US

IV. Provider business mailing address

863 OCEAN HWY W
SUPPLY NC
28462-4059
US

V. Phone/Fax

Practice location:
  • Phone: 910-995-7022
  • Fax:
Mailing address:
  • Phone: 910-755-1200
  • Fax: 910-755-1064

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

VIII. Authorized Official

Name: DR. MARY RUDD CRICHTON
Title or Position: FAMILY NURSE PRACTITIONER
Credential: DNP
Phone: 910-755-1200