Provider Demographics
NPI:1851443840
Name:COASTAL VISION CENTER
Entity Type:Organization
Organization Name:COASTAL VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RANDY
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:OD, PA
Authorized Official - Phone:910-792-0600
Mailing Address - Street 1:33 S KERR AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-1416
Mailing Address - Country:US
Mailing Address - Phone:910-792-0600
Mailing Address - Fax:910-799-5162
Practice Address - Street 1:33 S KERR AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1416
Practice Address - Country:US
Practice Address - Phone:910-792-0600
Practice Address - Fax:910-799-5162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1548152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890913PMedicaid
NC890913PMedicaid