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General NPI Number Information
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NPI Number | 1124307509
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Entity Type | Organization
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Legal Business Name | COASTAL CAROLINA MEDICAL CENTER, INC
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Dates
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Enumeration Date | 08/16/2011
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Last Update Date | 03/22/2022
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Provider Practice Location Address
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Address Line | 10911 N JACOB SMART BLVD D
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City | RIDGELAND
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State | SC
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Zip | 29936-2729
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Country | US
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Telephone | 843-784-3101
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Fax | 843-784-5313
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Provider Business Mailing Address
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Address Line | PO BOX 741261
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City | ATLANTA
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State | GA
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Zip | 30374-1261
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Country | US
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Telephone | 843-784-3101
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Fax | 843-784-5313
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Authorized Official
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Title or Position | CFO
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Name | RON GROTELUSCHEN
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Credential |
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Telephone | 843-784-8076
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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