Provider Demographics
NPI:1932344454
Name:COASTAL CAROLINA PHYSICAL REHAB INC
Entity Type:Organization
Organization Name:COASTAL CAROLINA PHYSICAL REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALFONSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-347-4175
Mailing Address - Street 1:P O BOX 32217
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588
Mailing Address - Country:US
Mailing Address - Phone:843-347-4175
Mailing Address - Fax:843-347-4179
Practice Address - Street 1:235 SINGLETON RIDGE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-347-4175
Practice Address - Fax:843-347-4179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD21577174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21577OtherSC MEDICAL LICENSE
SCAA27320281Medicare PIN