Provider Demographics
NPI:1386194397
Name:COASTAL CAROLINA HEALTH CARE PA
Entity Type:Organization
Organization Name:COASTAL CAROLINA HEALTH CARE PA
Other - Org Name:CCHC ORIENTAL MEDICAL CENTER
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 1:901 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ORIENTAL
Mailing Address - State:NC
Mailing Address - Zip Code:28571-9783
Mailing Address - Country:US
Mailing Address - Phone:252-249-2888
Mailing Address - Fax:
Practice Address - Street 1:901 BROAD ST
Practice Address - Street 2:
Practice Address - City:ORIENTAL
Practice Address - State:NC
Practice Address - Zip Code:28571-9783
Practice Address - Country:US
Practice Address - Phone:252-249-2888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care