Provider Demographics
NPI:1508910977
Name:COASTAL OPTICAL INCORPORATED
Entity Type:Organization
Organization Name:COASTAL OPTICAL INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:L
Authorized Official - Last Name:RATELIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-546-0442
Mailing Address - Street 1:1200 HIGHMARKET ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-3227
Mailing Address - Country:US
Mailing Address - Phone:843-546-0442
Mailing Address - Fax:843-546-1173
Practice Address - Street 1:1200 HIGHMARKET ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3227
Practice Address - Country:US
Practice Address - Phone:843-546-0442
Practice Address - Fax:843-546-1173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9921Medicaid