Provider Demographics
NPI:1679104293
Name:CRYSTAL COAST WELLNESS AND PERFORMANCE CENTER
Entity type:Organization
Organization Name:CRYSTAL COAST WELLNESS AND PERFORMANCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAYME
Authorized Official - Middle Name:
Authorized Official - Last Name:LIMBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LDN
Authorized Official - Phone:252-808-5623
Mailing Address - Street 1:4913 BRIDGES ST EXT STE 102
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-8978
Mailing Address - Country:US
Mailing Address - Phone:252-808-5623
Mailing Address - Fax:
Practice Address - Street 1:4913 BRIDGES ST EXT STE 102
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-8978
Practice Address - Country:US
Practice Address - Phone:252-808-5623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-01
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1699336156Medicaid