MEDICARE: COASTAL CAROLINAS INTEGRATED MEDICINE II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center
2	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1255158788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CAROLINAS INTEGRATED MEDICINE II

Provider Business Mailing Address
First Line	:	PO BOX 4563
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29597-4563
Country	:	US
Telephone Number	:	843-663-0933
Fax Number	:	843-663-0936

Provider Business Practice Location Address
First Line	:	416 MAIN ST
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-3024
Country	:	US
Telephone Number	:	843-663-0933
Fax Number	:	843-663-0936

Authorized Official
Title or Position	:	CREDENTIALING AND BILLING REP
Name	:	LA BOMMIE SAUNDERS
Credential	:
Telephone Number	:	910-616-5770

Provider Enumeration Date	:	09/25/2024
Last Update Date	:	09/25/2024

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