Healthcare Provider Details

I. General information

NPI: 1508910977
Provider Name (Legal Business Name): COASTAL OPTICAL INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HIGHMARKET ST SUITE 200
GEORGETOWN SC
29440-3227
US

IV. Provider business mailing address

1200 HIGHMARKET ST SUITE 200
GEORGETOWN SC
29440-3227
US

V. Phone/Fax

Practice location:
  • Phone: 843-546-0442
  • Fax: 843-546-1173
Mailing address:
  • Phone: 843-546-0442
  • Fax: 843-546-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateSC

VIII. Authorized Official

Name: MRS. CAROL L. RATELIFF
Title or Position: OFFICE MANAGER
Credential:
Phone: 843-546-0442