Provider Demographics
NPI:1609893650
Name:COASTAL EYE CARE LLC
Entity Type:Organization
Organization Name:COASTAL EYE CARE LLC
Other - Org Name:COASTAL EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:HICKS
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-638-8652
Mailing Address - Street 1:312 REDFERN VLG
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2522
Mailing Address - Country:US
Mailing Address - Phone:912-638-8652
Mailing Address - Fax:912-638-0490
Practice Address - Street 1:312 REDFERN VLG
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2522
Practice Address - Country:US
Practice Address - Phone:912-638-8652
Practice Address - Fax:912-638-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP3399Medicare UPIN
GAGRP3399Medicare ID - Type Unspecified
GA1268460001Medicare NSC