Provider Demographics
NPI:1063764686
Name:BLUE WATER COASTAL, LLC
Entity type:Organization
Organization Name:BLUE WATER COASTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILKIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:760-729-3200
Mailing Address - Street 1:PO BOX 1176
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-7176
Mailing Address - Country:US
Mailing Address - Phone:858-509-7999
Mailing Address - Fax:858-509-3993
Practice Address - Street 1:785 GRAND AVE
Practice Address - Street 2:#100
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2370
Practice Address - Country:US
Practice Address - Phone:760-729-3200
Practice Address - Fax:760-729-3201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29910111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC29910Medicare PIN