=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972081941
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL CAROLINA COSMETIC FACIAL SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2018
-----------------------------------------------------
Last Update Date | 12/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 TOWNE CENTRE PKWY
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29579-3493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-448-1621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6210 N OCEAN BLVD
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29572-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-201-5801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MICHAEL JOHNSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 720-201-5801
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
-----------------------------------------------------
License Number | 8911
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------