| Intracoastal Executive Wellness | |
|
606 W West St Ste 202 Southport NC 28461-3850 | |
| (910) 286-7420 | |
| Not Available |
| Full Name | Intracoastal Executive Wellness |
|---|---|
| Speciality | Internal Medicine |
| Location | 606 W West St Ste 202, Southport, North Carolina |
| Authorized Official Name and Position | Richard Wayne Hilliard (MEMBER) |
| Authorized Official Contact | 9102867420 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Intracoastal Executive Wellness 606 W West St Ste 202 Southport NC 28461-3850 Ph: (910) 286-7420 | Intracoastal Executive Wellness 606 W West St Ste 202 Southport NC 28461-3850 Ph: (910) 286-7420 |
| NPI Number | 1013760172 |
|---|---|
| Provider Enumeration Date | 04/09/2024 |
| Last Update Date | 04/09/2024 |
| Medicare PECOS PAC ID | 3274078522 |
|---|---|
| Medicare Enrollment ID | O20240711001901 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1013760172 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (* (Not Available)) | Primary |
| Provider Name | Richard W Hilliard |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1710116959 PECOS PAC ID: 4082863170 Enrollment ID: I20121004000741 |
| Provider Name | Edgar E |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1790526150 PECOS PAC ID: 9931644184 Enrollment ID: I20240821000559 |
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