Healthcare Provider Details

I. General information

NPI: 1861161044
Provider Name (Legal Business Name): COASTAL COMPREHENSIVE CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 S MADISON ST
WHITEVILLE NC
28472-4613
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 910-663-2273
  • Fax: 910-663-4050
Mailing address:
  • Phone: 910-663-2273
  • Fax: 910-663-4050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ALECIA ROBERTS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 910-663-2273