Provider Demographics
NPI:1114496734
Name:COASTAL VIRGINIA SPINE AND PAIN CENTER LLC
Entity Type:Organization
Organization Name:COASTAL VIRGINIA SPINE AND PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-340-3489
Mailing Address - Street 1:PO BOX 2546
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23450-2546
Mailing Address - Country:US
Mailing Address - Phone:757-340-3489
Mailing Address - Fax:757-340-4278
Practice Address - Street 1:4525 SOUTH BLVD STE 200
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1147
Practice Address - Country:US
Practice Address - Phone:757-227-3820
Practice Address - Fax:757-226-9021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-14
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty