Healthcare Provider Details

I. General information

NPI: 1497145627
Provider Name (Legal Business Name): COASTAL PAIN CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8626 DORCHESTER RD STE 101
NORTH CHARLESTON SC
29420-7328
US

IV. Provider business mailing address

8626 DORCHESTER RD STE 101
NORTH CHARLESTON SC
29420-7328
US

V. Phone/Fax

Practice location:
  • Phone: 843-327-3791
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number24890
License Number StateSC

VIII. Authorized Official

Name: THOMAS C WILLS
Title or Position: PRESIDENT
Credential: DC
Phone: 843-327-3791