Basic Information
| Provider Information | |||||||||
| NPI: | 1184278335 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL CAROLINA HEALTH CARE, PA | ||||||||
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| OtherOrganizationName: | CCHC CRAVEN PODIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12248 | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285612248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525146685 | ||||||||
| FaxNumber: | 2525142745 | ||||||||
| Practice Location | |||||||||
| Address1: | 1421 S GLENBURNIE RD # D | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285622603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526373988 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2019 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | NUCKOLLS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2525146685 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.