Provider Demographics
NPI:1164776514
Name:RJG COASTAL CHIROPRACTIC P.A.
Entity Type:Organization
Organization Name:RJG COASTAL CHIROPRACTIC P.A.
Other - Org Name:HEALTHSOURCE OF DESTIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-654-6912
Mailing Address - Street 1:35008 EMERALD COAST PKWY
Mailing Address - Street 2:STE 202
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-4754
Mailing Address - Country:US
Mailing Address - Phone:850-654-6912
Mailing Address - Fax:850-654-9459
Practice Address - Street 1:35008 EMERALD COAST PKWY
Practice Address - Street 2:STE 202
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-4754
Practice Address - Country:US
Practice Address - Phone:850-654-6912
Practice Address - Fax:850-654-9459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 10579111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGM 188ZOtherMEDICARE PTAN
3632568OtherCIGNA