Healthcare Provider Details

I. General information

NPI: 1538558879
Provider Name (Legal Business Name): COASTAL CHILDRENS SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

V. Phone/Fax

Practice location:
  • Phone: 910-772-9402
  • Fax: 910-772-9452
Mailing address:
  • Phone: 910-772-9402
  • Fax: 910-772-9452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. FERNANDO R MOYA
Title or Position: PRESIDENT
Credential: MD
Phone: 910-667-5011