Provider Demographics
NPI:1780728824
Name:COASTAL GRAND EYE ASSOCIATES LTD. CO.
Entity type:Organization
Organization Name:COASTAL GRAND EYE ASSOCIATES LTD. CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:CUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:843-424-2553
Mailing Address - Street 1:PO BOX 50864
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-0015
Mailing Address - Country:US
Mailing Address - Phone:843-444-0090
Mailing Address - Fax:843-444-0377
Practice Address - Street 1:1512 COASTAL GRAND CIRCLE
Practice Address - Street 2:C 330
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-9779
Practice Address - Country:US
Practice Address - Phone:843-444-0090
Practice Address - Fax:843-444-0377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1237152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8014Medicare PIN