Provider Demographics
NPI:1871519165
Name:EMERALD COAST CHIROPRACTIC INC
Entity type:Organization
Organization Name:EMERALD COAST CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:CALLAHAN
Authorized Official - Last Name:JACKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-678-8048
Mailing Address - Street 1:705 JOHN SIMS PKWY W
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1878
Mailing Address - Country:US
Mailing Address - Phone:850-678-8048
Mailing Address - Fax:850-678-2629
Practice Address - Street 1:705 JOHN SIMS PKWY W
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1878
Practice Address - Country:US
Practice Address - Phone:850-678-8048
Practice Address - Fax:850-678-2629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0007070111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55426OtherBLUE CROSS BLUE SHIELD
FLDA1478OtherRAILRAOD MEDICARE
FLDA1478OtherRAILRAOD MEDICARE