Provider Demographics
NPI:1285147801
Name:COASTAL CHIROPRACTIC LLC
Entity type:Organization
Organization Name:COASTAL CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-829-2998
Mailing Address - Street 1:137 FOX DEN RD
Mailing Address - Street 2:
Mailing Address - City:CHURCH HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21623-1437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:717 GOLDSBOROUGH ST
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-4914
Practice Address - Country:US
Practice Address - Phone:410-829-2998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01998111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty