Provider Demographics
NPI:1437311248
Name:COASTAL CHILDRENS CLINIC
Entity Type:Organization
Organization Name:COASTAL CHILDRENS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-633-2900
Mailing Address - Street 1:703 NEWMAN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1004 JENKINS AVENUE
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28555
Practice Address - Country:US
Practice Address - Phone:252-633-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901346Medicaid