Provider Demographics
NPI:1508511767
Name:SANDY SHORES PRIMARY CARE, PLLC
Entity Type:Organization
Organization Name:SANDY SHORES PRIMARY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:L
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:910-789-9883
Mailing Address - Street 1:13741 NC HIGHWAY 50 STE A
Mailing Address - Street 2:
Mailing Address - City:SURF CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28445-6935
Mailing Address - Country:US
Mailing Address - Phone:910-777-2782
Mailing Address - Fax:
Practice Address - Street 1:13741 NC HIGHWAY 50 STE A
Practice Address - Street 2:
Practice Address - City:SURF CITY
Practice Address - State:NC
Practice Address - Zip Code:28445-6935
Practice Address - Country:US
Practice Address - Phone:910-777-2732
Practice Address - Fax:910-777-2742
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANDY SHORES MEDICAL CENTER AND URGENT CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1104159540Medicaid