Provider Demographics
NPI:1255158788
Name:COASTAL CAROLINAS INTEGRATED MEDICINE II
Entity type:Organization
Organization Name:COASTAL CAROLINAS INTEGRATED MEDICINE II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AND BILLING REP
Authorized Official - Prefix:
Authorized Official - First Name:LA BOMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUNDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-616-5770
Mailing Address - Street 1:PO BOX 4563
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29597-4563
Mailing Address - Country:US
Mailing Address - Phone:843-663-0933
Mailing Address - Fax:843-663-0936
Practice Address - Street 1:416 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-3024
Practice Address - Country:US
Practice Address - Phone:843-663-0933
Practice Address - Fax:843-663-0936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care