Provider Demographics
NPI:1093892473
Name:COASTAL CHIROPRACTIC PA
Entity Type:Organization
Organization Name:COASTAL CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:954-946-3703
Mailing Address - Street 1:2323 NE 26TH AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-1147
Mailing Address - Country:US
Mailing Address - Phone:954-946-3703
Mailing Address - Fax:954-943-2280
Practice Address - Street 1:2323 NE 26TH AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-1147
Practice Address - Country:US
Practice Address - Phone:954-946-3703
Practice Address - Fax:954-943-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0007854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL51835OtherBLUE CROSS BLUE SHIELD
FL381743100Medicaid
FL381743100Medicaid
FL51835OtherBLUE CROSS BLUE SHIELD