MEDICARE: COASTAL CAR

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	251S00000X	Community/Behavioral Health Agency	P008674	NC

General Provider Information

NPI Number	:	1396150611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CAR

Provider Business Mailing Address
First Line	:	1003 ST. ANDREWS DRIVE
Second Line	:	APT. #103
City	:	WILMINGTON
State	:	NC
Zip	:	28412
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	609 SHIPYARD BLVD
Second Line	:	UNIT 102
City	:	WILMINGTON
State	:	NC
Zip	:	28412-6562
Country	:	US
Telephone Number	:	910-620-8301
Fax Number	:

Authorized Official
Title or Position	:	TEAM LEAD
Name	:	TAQUICIA CARR
Credential	:	LCSWA
Telephone Number	:	910-620-8301

Provider Enumeration Date	:	06/25/2014
Last Update Date	:	06/25/2014

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