Healthcare Provider Details

I. General information

NPI: 1932274743
Provider Name (Legal Business Name): COASTAL CAROLINA CENTERS OF UROLOGY AND SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 FARRAR DRIVE
CONWAY SC
29526-8747
US

IV. Provider business mailing address

822 FARRAR DR
CONWAY SC
29526-8747
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-9587
  • Fax: 843-347-9633
Mailing address:
  • Phone: 843-347-9587
  • Fax: 843-347-9633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. VIRGINIA A MCCURDY
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 843-347-9587