Coastal Carolinas Integrated Medicine PA
Organization Active NPI Pain Medicine (Physical Medicine & Rehabilitation) Physician · Supply, NC
NPI 1649304239 · NPPES record last updated Jul 9, 2025
Key facts
- NPI
- 1649304239
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pain Medicine (Physical Medicine & Rehabilitation) Physician 2081P2900X
- License
- 36621 (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
- Organization subpart
- No
Authorized official
- Name
- Dr. Kenneth Lee Willeford, M.D.
- Title
- Owner
- Phone
- (910) 755-6060
Practitioners 2
-
Kenneth Lee Willeford, M.D.
-
Carleen Willeford, DNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 34D2139750 | Coastal Carolinas Integrated Medicine | Certificate of waiver | Nov 7, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in NC, SC
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050201000946 | NC | Part B Supplier - Clinic/Group Practice | 6406807072 |
Receives reassigned benefits from 1 practitioner Practice locations: Supply, NC |
| O20241113002679 | SC | Part B Supplier - Clinic/Group Practice | 6406807072 |
Receives reassigned benefits from 1 practitioner Practice locations: North Myrtle Beach, SC |
National Provider Directory
Locations
10 Doctors Cir
Ste 2
Supply, NC 28462
Phone (910) 755-6060
416 Main St
North Myrtle Beach, SC 29582
Phone (843) 663-0933
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pain Medicine (Physical Medicine & Rehabilitation) Physician |
2081P2900X | 36621 | NC | Yes |
Addresses
Primary practice location
10 Doctors Cir
Suite 2
Supply, NC 28462-4089
Mailing address
10 Doctors Cir
Suite 2
Supply, NC 28462-4089
Phone (910) 755-6060
Other practice location 1
416 Main St
North Myrtle Beach, SC 29582-3024
Phone (910) 755-6060
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 016UX | Other | NC | BCBS |
Other providers in Supply, NC
- Cedar Tree Ministries, Inc
- Chicora Medical Group PA
- Church Family Medicine, PC
- Sue A Clampitt
- Coastal Cancer Center LLC
- Coastal Gastroenterology PLLC
- Coastal Haven Home
- Coastal Hearing Centers, Inc
- Coastal Horizons Center Inc.
- Coastal Horizonscenter, Inc
All providers in Supply, NC · Pain Medicine (Physical Medicine & Rehabilitation) Physician in North Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 9, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.