1245402064 NPI number — COASTAL CAROLINA HEART LLC

Table of content: (NPI 1245402064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245402064 NPI number — COASTAL CAROLINA HEART LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL CAROLINA HEART LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245402064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10720 SIKES PL
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28277-8141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-708-6610
Provider Business Mailing Address Fax Number:
888-401-6931

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1604 PHYSICIANS DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28401-7362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-762-2292
Provider Business Practice Location Address Fax Number:
910-762-2208
Provider Enumeration Date:
04/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GUIDRY
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
704-708-6610

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 016N9 . This is a "BLUE CROSS BLUE SHIELD NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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