Healthcare Provider Details

I. General information

NPI: 1184730749
Provider Name (Legal Business Name): COASTAL CAROLINA MULTISPECIALTY ASSOCS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9221 UNIVERSITY BLVD SUITE 102
NORTH CHARLESTON SC
29406-9148
US

IV. Provider business mailing address

9221 UNIVERSITY BLVD SUITE 102
NORTH CHARLESTON SC
29406-9148
US

V. Phone/Fax

Practice location:
  • Phone: 843-576-0700
  • Fax: 843-576-0701
Mailing address:
  • Phone: 843-576-0700
  • Fax: 843-576-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MARK PICKETT
Title or Position: VICE-PRESIDENT OF OPERATIONS
Credential:
Phone: 678-762-5037