Provider Demographics
NPI:1881654838
Name:COASTAL CAROLINA ESWT, LLC
Entity Type:Organization
Organization Name:COASTAL CAROLINA ESWT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:STROMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-367-3798
Mailing Address - Street 1:100 W 3RD AVE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-3256
Mailing Address - Country:US
Mailing Address - Phone:866-367-3798
Mailing Address - Fax:614-291-9452
Practice Address - Street 1:100 W 3RD AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-3256
Practice Address - Country:US
Practice Address - Phone:866-367-3798
Practice Address - Fax:614-291-9452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty