Provider Demographics
NPI:1760226419
Name:COASTAL CAROLINA ENT
Entity type:Organization
Organization Name:COASTAL CAROLINA ENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:KINKEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-663-9090
Mailing Address - Street 1:3806 SAWTELL RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-7873
Mailing Address - Country:US
Mailing Address - Phone:846-663-9090
Mailing Address - Fax:843-663-9091
Practice Address - Street 1:3806 SAWTELL RD
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7873
Practice Address - Country:US
Practice Address - Phone:843-663-9090
Practice Address - Fax:843-663-9091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty