Healthcare Provider Details

I. General information

NPI: 1134801160
Provider Name (Legal Business Name): COASTAL REJUVENATION SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 CHESTNUT RD
MYRTLE BEACH SC
29572-5502
US

IV. Provider business mailing address

630 CHESTNUT RD
MYRTLE BEACH SC
29572-5502
US

V. Phone/Fax

Practice location:
  • Phone: 843-945-1452
  • Fax: 843-945-1489
Mailing address:
  • Phone: 843-945-1452
  • Fax: 843-945-1489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LAURA C CRAWFORD
Title or Position: OWNER
Credential: MSW
Phone: 843-945-1452