Provider Demographics
NPI:1851348981
Name:COASTAL REHABILITATION ASSOCIATES
Entity Type:Organization
Organization Name:COASTAL REHABILITATION ASSOCIATES
Other - Org Name:COASTAL REHABILITATION MEDICINE ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-794-8892
Mailing Address - Street 1:PO BOX 4217
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28406-1217
Mailing Address - Country:US
Mailing Address - Phone:910-794-8892
Mailing Address - Fax:910-794-8895
Practice Address - Street 1:2800 ASHTON DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2486
Practice Address - Country:US
Practice Address - Phone:910-794-8892
Practice Address - Fax:910-794-8895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890191YMedicaid
NC890191YMedicaid