Basic Information
| Provider Information | |||||||||
| NPI: | 1891282638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL CAROLINA HEALTH CARE, PA | ||||||||
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| OtherOrganizationName: | CCHC HAVELOCK PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12248 | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285612248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525146685 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1224 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HAVELOCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285322405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524477474 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2018 | ||||||||
| LastUpdateDate: | 04/17/2018 | ||||||||
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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 | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.