Healthcare Provider Details

I. General information

NPI: 1093280620
Provider Name (Legal Business Name): CAPESIDE ADDICTION CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4889 HIGHWAY 17 BYP S
MYRTLE BEACH SC
29577-6683
US

IV. Provider business mailing address

311 4 E JUDGES ROAD
WILMINGTON NC
28405
US

V. Phone/Fax

Practice location:
  • Phone: 843-584-7011
  • Fax: 843-945-1355
Mailing address:
  • Phone: 910-791-6767
  • Fax: 910-399-2190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM BEASLEY
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 910-791-6767