Provider Demographics
NPI:1568401156
Name:COASTAL CAROLINA HEALTH CARE PA
Entity Type:Organization
Organization Name:COASTAL CAROLINA HEALTH CARE PA
Other - Org Name:CCHC COASTAL PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NUCKOLLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-514-6685
Mailing Address - Street 1:670 CARDINAL PL
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5201
Mailing Address - Country:US
Mailing Address - Phone:252-636-6222
Mailing Address - Fax:252-636-5385
Practice Address - Street 1:670 CARDINAL PLACE
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562
Practice Address - Country:US
Practice Address - Phone:252-636-6222
Practice Address - Fax:252-636-5385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890254WMedicaid
NC0254WOtherBCBS OF NC
NC0254WOtherBCBS OF NC
NC890254WMedicaid