=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508511767
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANDY SHORES PRIMARY CARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2022
-----------------------------------------------------
Last Update Date | 02/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13741 NC HIGHWAY 50 STE A
-----------------------------------------------------
City | SURF CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28445-6935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-777-2732
-----------------------------------------------------
Fax | 910-777-2742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13741 NC HIGHWAY 50 STE A
-----------------------------------------------------
City | SURF CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28445-6935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-777-2782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | REBECCA L COOPER
-----------------------------------------------------
Credential | PAC
-----------------------------------------------------
Telephone | 910-789-9883
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------