Provider Demographics
NPI:1912925371
Name:COASTAL CHIROPRACTIC CENTER PA
Entity type:Organization
Organization Name:COASTAL CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:ADRIAN
Authorized Official - Last Name:VANCAMPEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-343-1111
Mailing Address - Street 1:PO BOX 12027
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-0100
Mailing Address - Country:US
Mailing Address - Phone:910-343-1111
Mailing Address - Fax:910-343-8292
Practice Address - Street 1:3825 MARKET ST
Practice Address - Street 2:SUITE #1
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1453
Practice Address - Country:US
Practice Address - Phone:910-343-1111
Practice Address - Fax:910-343-8292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908304Medicaid
NC08304OtherBCBSNC
NC2446381Medicare ID - Type UnspecifiedCOASTAL CHIROPRACTIC