Provider Demographics
NPI:1902077266
Name:COASTAL WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:COASTAL WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:CONGDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-467-1117
Mailing Address - Street 1:4955 HIGHWAY 17 BYP S
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-6684
Mailing Address - Country:US
Mailing Address - Phone:888-403-2444
Mailing Address - Fax:855-818-2168
Practice Address - Street 1:4955 HIGHWAY 17 BYP S
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-6684
Practice Address - Country:US
Practice Address - Phone:888-403-2444
Practice Address - Fax:855-818-2168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7038Medicaid