Provider Demographics
NPI:1306653746
Name:COASTAL CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:COASTAL CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:TESTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-455-6540
Mailing Address - Street 1:59 RAIN TREE LN
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-6428
Mailing Address - Country:US
Mailing Address - Phone:843-455-6540
Mailing Address - Fax:
Practice Address - Street 1:9428 OCEAN HWY STE 1
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-8259
Practice Address - Country:US
Practice Address - Phone:843-237-1919
Practice Address - Fax:843-237-7694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty