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
State | License ID | Taxonomies |
---|---|---|
MS | 0866 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Single Specialty |