Provider Demographics
NPI:1588938765
Name:CORAL REEF CHIROPRACTIC CENTER PA
Entity type:Organization
Organization Name:CORAL REEF CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:PEPIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:305-255-2499
Mailing Address - Street 1:9044 SW 152ND ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1928
Mailing Address - Country:US
Mailing Address - Phone:305-255-2499
Mailing Address - Fax:305-252-9849
Practice Address - Street 1:9044 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1928
Practice Address - Country:US
Practice Address - Phone:305-255-2499
Practice Address - Fax:305-252-9849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006601111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380291400Medicaid
FL380291400Medicaid