Healthcare Provider Details

I. General information

NPI: 1245612035
Provider Name (Legal Business Name): COASTAL PAIN CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3203 HIGHWAY 9 E SUITE B
LITTLE RIVER SC
29566-8143
US

IV. Provider business mailing address

3203 HIGHWAY 9 E SUITE B
LITTLE RIVER SC
29566-8143
US

V. Phone/Fax

Practice location:
  • Phone: 843-491-1480
  • Fax:
Mailing address:
  • Phone: 843-491-1480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DARIN WILLARD
Title or Position: MANAGING MEMBER
Credential:
Phone: 304-553-3457