1932344454 NPI number — COASTAL CAROLINA PHYSICAL REHAB INC

Table of content: (NPI 1932344454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932344454 NPI number — COASTAL CAROLINA PHYSICAL REHAB INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL CAROLINA PHYSICAL REHAB INC
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:
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:
1932344454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 32217
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29588
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-347-4175
Provider Business Mailing Address Fax Number:
843-347-4179

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
235 SINGLETON RIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-347-4175
Provider Business Practice Location Address Fax Number:
843-347-4179
Provider Enumeration Date:
12/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ALFONSO
Authorized Official First Name:
MAYRA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
843-347-4175

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD21577 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD21577 . This is a "SC MEDICAL LICENSE" identifier . This identifiers is of the category "OTHER".




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