Provider Demographics
NPI:1154490688
Name:COASTAL BREEZE CHIROPRACTIC
Entity Type:Organization
Organization Name:COASTAL BREEZE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:DUNCAN
Authorized Official - Last Name:EDGAR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-575-7809
Mailing Address - Street 1:PO BOX 6931
Mailing Address - Street 2:
Mailing Address - City:OCEAN ISLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28469-0931
Mailing Address - Country:US
Mailing Address - Phone:910-575-7809
Mailing Address - Fax:
Practice Address - Street 1:109 CAUSEWAY DR STE 6
Practice Address - Street 2:
Practice Address - City:OCEAN ISLE BEACH
Practice Address - State:NC
Practice Address - Zip Code:28469-7523
Practice Address - Country:US
Practice Address - Phone:910-575-7809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2207111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7908776Medicaid
NC2340746Medicare PIN
NCUO2665Medicare UPIN