Healthcare Provider Details

I. General information

NPI: 1114688702
Provider Name (Legal Business Name): COASTAL CAROLINA CONCIERGE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 01/05/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3942 MARKET ST
WILMINGTON NC
28403-1488
US

IV. Provider business mailing address

1812 TREY CT
WILMINGTON NC
28403-3718
US

V. Phone/Fax

Practice location:
  • Phone: 910-616-7718
  • Fax:
Mailing address:
  • Phone: 109-616-7718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: EVAN T MANN
Title or Position: PRESIDENT
Credential:
Phone: 910-616-7718