Provider Demographics
NPI:1689777849
Name:COASTAL VISION CARE LLC
Entity Type:Organization
Organization Name:COASTAL VISION CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:ROSALIE
Authorized Official - Last Name:JURAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-693-2505
Mailing Address - Street 1:PO BOX 23
Mailing Address - Street 2:
Mailing Address - City:ISLE OF PALMS
Mailing Address - State:SC
Mailing Address - Zip Code:29451
Mailing Address - Country:US
Mailing Address - Phone:843-693-2505
Mailing Address - Fax:843-553-7335
Practice Address - Street 1:605 SAINT JAMES AVE
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445
Practice Address - Country:US
Practice Address - Phone:843-863-1215
Practice Address - Fax:843-553-7335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC0956152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9726Medicaid
SCD09569Medicaid