Provider Demographics
NPI:1871069732
Name:COASTAL CITY CHIROPRACTIC CENTER LLC
Entity type:Organization
Organization Name:COASTAL CITY CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:CHELSIE
Authorized Official - Last Name:DEMAIO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:941-504-2257
Mailing Address - Street 1:3939 S ATLANTIC AVE APT A
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-6521
Mailing Address - Country:US
Mailing Address - Phone:941-504-2257
Mailing Address - Fax:
Practice Address - Street 1:4550 CLYDE MORRIS BLVD STE D
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4080
Practice Address - Country:US
Practice Address - Phone:941-504-2257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty