MEDICARE: COASTAL CAROLINA HEALTH CARE PA

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	261QS1200X	Sleep Disorder Diagnostic Clinic/Center
2	207RS0012X	Sleep Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1376582965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CAROLINA HEALTH CARE PA

Provider Business Mailing Address
First Line	:	1020 MEDICAL PARK AVE
Second Line	:
City	:	NEW BERN
State	:	NC
Zip	:	28562-5248
Country	:	US
Telephone Number	:	252-634-2240
Fax Number	:	252-634-2241

Provider Business Practice Location Address
First Line	:	1020 MEDICAL PARK AVE
Second Line	:
City	:	NEW BERN
State	:	NC
Zip	:	28562-0000
Country	:	US
Telephone Number	:	252-634-2240
Fax Number	:	252-634-2241

Authorized Official
Title or Position	:	CEO
Name	:	MR. STEPHEN NUCKOLLS
Credential	:
Telephone Number	:	252-514-6685

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	02/01/2024

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