Healthcare Provider Details

I. General information

NPI: 1639336027
Provider Name (Legal Business Name): COASTAL CAROLINA FOOT & ANKLE ASSOCIATION PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 N NORWOOD ST
WALLACE NC
28466-2730
US

IV. Provider business mailing address

114 N NORWOOD ST
WALLACE NC
28466-2730
US

V. Phone/Fax

Practice location:
  • Phone: 910-285-3362
  • Fax: 910-285-6683
Mailing address:
  • Phone: 910-285-3362
  • Fax: 910-285-6683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number449
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number230
License Number StateNC

VIII. Authorized Official

Name: MRS. KATHY N WALKER
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 910-343-8889