Provider Demographics
NPI:1306009303
Name:COAST NERVE & SPINE CENTER, LLC
Entity type:Organization
Organization Name:COAST NERVE & SPINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEPPER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:228-831-5554
Mailing Address - Street 1:PO BOX 3853
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-3853
Mailing Address - Country:US
Mailing Address - Phone:228-831-5554
Mailing Address - Fax:228-831-5505
Practice Address - Street 1:15037 DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3284
Practice Address - Country:US
Practice Address - Phone:228-831-5554
Practice Address - Fax:228-831-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0866111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty