Provider Demographics
NPI:1013033927
Name:SPACE COAST CHIROPRACTIC INC
Entity Type:Organization
Organization Name:SPACE COAST CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-729-9000
Mailing Address - Street 1:1070 S WICKHAM ROAD
Mailing Address - Street 2:SPACE COAST CHIROPRACTIC INC
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904
Mailing Address - Country:US
Mailing Address - Phone:321-729-9000
Mailing Address - Fax:321-722-3997
Practice Address - Street 1:1070 S WICKHAM ROAD
Practice Address - Street 2:SPACE COAST CHIROPRACTIC INC
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904
Practice Address - Country:US
Practice Address - Phone:321-729-9000
Practice Address - Fax:321-722-3997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8196111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1628516000OtherACS-DEPARTMENT OF LABOR