Provider Demographics
NPI:1710136908
Name:COASTAL CAROLINA UNIVERSITY
Entity Type:Organization
Organization Name:COASTAL CAROLINA UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NIRSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:843-349-6543
Mailing Address - Street 1:204 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8834
Mailing Address - Country:US
Mailing Address - Phone:843-649-6543
Mailing Address - Fax:
Practice Address - Street 1:204 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8834
Practice Address - Country:US
Practice Address - Phone:843-649-6543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3684261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center