Healthcare Provider Details

I. General information

NPI: 1740389170
Provider Name (Legal Business Name): COASTAL RADIOLOGY CONSULTANTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 DURHAM RD SUITE A
WAKE FOREST NC
27587
US

IV. Provider business mailing address

851 A DURHAM ROAD
WAKE FOREST NC
27587
US

V. Phone/Fax

Practice location:
  • Phone: 919-562-6570
  • Fax: 919-562-6572
Mailing address:
  • Phone: 919-562-6570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number2160
License Number StateNC

VIII. Authorized Official

Name: DR. KATHY J THORN
Title or Position: OWNER
Credential: D.C., D.A.C.B.R.
Phone: 919-562-6570