Provider Demographics
NPI:1942522719
Name:COASTAL CAROLINA PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:COASTAL CAROLINA PRIMARY CARE, LLC
Other - Org Name:DOC AT THE DOOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:O
Authorized Official - Last Name:WINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-847-4054
Mailing Address - Street 1:3601 LADSON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4304
Mailing Address - Country:US
Mailing Address - Phone:843-821-0733
Mailing Address - Fax:843-821-0925
Practice Address - Street 1:3601 LADSON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4304
Practice Address - Country:US
Practice Address - Phone:843-821-0733
Practice Address - Fax:843-821-0925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1942522719Medicaid
SCGP5390Medicaid