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General NPI Number Information
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NPI Number | 1689777849
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Entity Type | Organization
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Legal Business Name | COASTAL VISION CARE LLC
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Dates
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Enumeration Date | 09/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 605 SAINT JAMES AVE
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City | GOOSE CREEK
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State | SC
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Zip | 29445
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Country | US
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Telephone | 843-863-1215
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Fax | 843-553-7335
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Provider Business Mailing Address
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Address Line | PO BOX 23
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City | ISLE OF PALMS
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State | SC
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Zip | 29451
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Country | US
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Telephone | 843-693-2505
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Fax | 843-553-7335
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Authorized Official
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Title or Position | OWNER
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Name | DR. DIANE ROSALIE JURAS
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Credential | OD
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Telephone | 843-693-2505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | SC0956
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License Number State | SC
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