Provider Demographics
NPI:1992858237
Name:COASTAL CAROLINA RESPIRATORY SERVICES, INC
Entity Type:Organization
Organization Name:COASTAL CAROLINA RESPIRATORY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:RRT, RCP, AE-C
Authorized Official - Phone:910-298-6007
Mailing Address - Street 1:106 S. BROWN ROAD
Mailing Address - Street 2:
Mailing Address - City:BEULAVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28518-0467
Mailing Address - Country:US
Mailing Address - Phone:910-298-6007
Mailing Address - Fax:
Practice Address - Street 1:106 S. BROWN ROAD
Practice Address - Street 2:
Practice Address - City:BEULAVILLE
Practice Address - State:NC
Practice Address - Zip Code:28518-0467
Practice Address - Country:US
Practice Address - Phone:919-920-8916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704680Medicaid
NC7704680Medicaid