Provider Demographics
NPI:1093209546
Name:CRYSTAL COAST PAIN MANAGEMENT CENTER, PLLC
Entity Type:Organization
Organization Name:CRYSTAL COAST PAIN MANAGEMENT CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-636-0300
Mailing Address - Street 1:2111 NEUSE BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28560-4318
Mailing Address - Country:US
Mailing Address - Phone:125-263-6030
Mailing Address - Fax:
Practice Address - Street 1:5053 EXECUTIVE DR STE B
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557
Practice Address - Country:US
Practice Address - Phone:252-726-8480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty