Provider Demographics
NPI:1073911822
Name:COASTAL CAROLINA HEALTH CARE PA
Entity Type:Organization
Organization Name:COASTAL CAROLINA HEALTH CARE PA
Other - Org Name:CCHC CREEKSIDE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:NUCKOLLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-514-6685
Mailing Address - Street 1:PO BOX 12248
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28561-2248
Mailing Address - Country:US
Mailing Address - Phone:252-672-0224
Mailing Address - Fax:252-672-0227
Practice Address - Street 1:1010 LATHAN LN
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-4002
Practice Address - Country:US
Practice Address - Phone:252-672-0224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-10
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty