Coastal Carolinas Integrated Medicine PA

Primary specialty

Pain Medicine (Physical Medicine & Rehabilitation) PhysicianTaxonomy code 2081P2900X

License

36621 Issued in NC

Legal business name

COASTAL CAROLINAS INTEGRATED MEDICINE PA

Practice address

10 Doctors Cir
Suite 2
Supply, NC 28462-4089

Phone

(910) 755-6060

Fax

(910) 939-1659

NPI assigned

Mar 15, 2007

Last updated

Jul 9, 2025By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Kenneth Lee Willeford, M.D.NPI 1912917865

Title

Owner

Phone

(910) 755-6060

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in NC, SC2 enrollments

Enrollment records 2

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Kenneth Lee Willeford, M.D.

  • Physical Medicine & Rehabilitation Physician
  • Supply, NC
  • NPI 1912917865

  SC

  Medicare reassignment NPD Authorized official
• Carleen Willeford, DNP

  • Family Nurse Practitioner
  • North Myrtle Beach, SC
  • NPI 1164641908

  Multi-Specialty

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173916800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1752019200000",
    "number": "1649304239",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10 DOCTORS CIR",
            "address_2": "SUITE 2",
            "city": "SUPPLY",
            "state": "NC",
            "postal_code": "284624089",
            "telephone_number": "910-755-6060",
            "fax_number": "910-755-6061"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10 DOCTORS CIR",
            "address_2": "SUITE 2",
            "city": "SUPPLY",
            "state": "NC",
            "postal_code": "284624089",
            "telephone_number": "910-755-6060",
            "fax_number": "910-939-1659"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "416 Main St",
            "address_purpose": "LOCATION",
            "city": "North Myrtle Beach",
            "state": "SC",
            "postal_code": "295823024",
            "country_code": "US",
            "telephone_number": "910-755-6060",
            "fax_number": "910-939-1659",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "COASTAL CAROLINAS INTEGRATED MEDICINE PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-15",
        "last_updated": "2025-07-09",
        "certification_date": "2025-07-09",
        "status": "A",
        "authorized_official_last_name": "WILLEFORD",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "910-755-6060",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "2081P2900X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physical Medicine & Rehabilitation, Pain Medicine",
            "state": "NC",
            "license": "36621",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Pain Medicine (Physical Medicine & Rehabilitation) Physician in Supply, NC
• Providers in Supply, NC by specialty
• Pain Medicine (Physical Medicine & Rehabilitation) Physician in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.