MEDICARE: COASTAL PAIN CARE, LLC

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	208VP0014X	Interventional Pain Medicine Physician	24890	SC

General Provider Information

NPI Number	:	1497145627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL PAIN CARE, LLC

Provider Business Mailing Address
First Line	:	8626 DORCHESTER RD
Second Line	:	STE 101
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29420-7328
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8626 DORCHESTER RD
Second Line	:	STE 101
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29420-7328
Country	:	US
Telephone Number	:	843-327-3791
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS C WILLS
Credential	:	DC
Telephone Number	:	843-327-3791

Provider Enumeration Date	:	01/26/2015
Last Update Date	:	01/26/2015

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