Provider Demographics
NPI:1295983096
Name:COASTAL CAROLINA BREAST CENTER LLC
Entity type:Organization
Organization Name:COASTAL CAROLINA BREAST CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CIAPPETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-651-3308
Mailing Address - Street 1:4181 HIGHWAY 17
Mailing Address - Street 2:P O BOX 3217
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-5019
Mailing Address - Country:US
Mailing Address - Phone:843-651-3308
Mailing Address - Fax:843-651-4629
Practice Address - Street 1:4181 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5019
Practice Address - Country:US
Practice Address - Phone:843-651-3308
Practice Address - Fax:843-651-4629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCF31432Medicare UPIN