1972081941 NPI number — COASTAL CAROLINA COSMETIC FACIAL SURGERY

Table of content: (NPI 1972081941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972081941 NPI number — COASTAL CAROLINA COSMETIC FACIAL SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL CAROLINA COSMETIC FACIAL SURGERY
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:
1972081941
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6210 N OCEAN BLVD
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:
29572-3300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-201-5801
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
133 TOWNE CENTRE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29579-3493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-448-1621
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
720-201-5801

Provider Taxonomy Codes

  • Taxonomy code: 261QS0112X , with the licence number:  8911 , 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)





Copyright © 2007-2025 www.npivalidator.com