Provider Demographics
NPI:1235126830
Name:COASTAL PEDIATRIC CARE, INC
Entity Type:Organization
Organization Name:COASTAL PEDIATRIC CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, PNP
Authorized Official - Phone:252-247-5212
Mailing Address - Street 1:212 N 35TH ST
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-3104
Mailing Address - Country:US
Mailing Address - Phone:252-247-5212
Mailing Address - Fax:252-247-1034
Practice Address - Street 1:212 N 35TH ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-3104
Practice Address - Country:US
Practice Address - Phone:252-247-5212
Practice Address - Fax:252-247-1034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000101Medicaid