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General NPI Number Information
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NPI Number | 1881619740
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Entity Type | Organization
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Legal Business Name | COASTAL CAROLINA INTERNAL MEDICINE, PA
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Dates
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Enumeration Date | 07/13/2006
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Last Update Date | 10/30/2019
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Provider Practice Location Address
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Address Line | 2420 HENDERSON DR
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City | JACKSONVILLE
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State | NC
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Zip | 28546-5254
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Country | US
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Telephone | 910-937-0008
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Fax | 910-937-0098
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Provider Business Mailing Address
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Address Line | 2420 HENDERSON DR
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City | JACKSONVILLE
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State | NC
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Zip | 28546-5254
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Country | US
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Telephone | 910-937-0008
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Fax | 910-937-0098
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. MITZI M ROS
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Credential | R.N
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Telephone | 910-937-0008
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 200200443
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License Number State | NC
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