Healthcare Provider Details

I. General information

NPI: 1205856556
Provider Name (Legal Business Name): COASTAL CANCER CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 09/02/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3008 BAYBORO ST
LORIS SC
29569-2714
US

IV. Provider business mailing address

8121 ROURK ST
MYRTLE BEACH SC
29572-4128
US

V. Phone/Fax

Practice location:
  • Phone: 843-756-0932
  • Fax: 843-692-5015
Mailing address:
  • Phone: 843-692-5000
  • Fax: 843-692-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number11181
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. VIJAY B PAUDEL
Title or Position: PARTNER
Credential: MD
Phone: 843-692-5000