Healthcare Provider Details

I. General information

NPI: 1386989028
Provider Name (Legal Business Name): COASTAL CAROLINA ENT, DO, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3806 SAWTELL RD
LITTLE RIVER SC
29566-7873
US

IV. Provider business mailing address

302 LIBERTY ST
WHITEVILLE NC
28472-3714
US

V. Phone/Fax

Practice location:
  • Phone: 843-663-9090
  • Fax: 843-663-9091
Mailing address:
  • Phone: 910-914-0540
  • Fax: 910-914-0640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberDO 1480
License Number StateSC

VIII. Authorized Official

Name: MS. WENDY C. PARIS
Title or Position: INSURANCE/BILLING SPECIALIST
Credential: CPC
Phone: 910-914-0540