Provider Demographics
NPI:1346679610
Name:COASTAL SPINE AND SPORT OF DAYTONA BEACH
Entity Type:Organization
Organization Name:COASTAL SPINE AND SPORT OF DAYTONA BEACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WOJCIK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-496-7998
Mailing Address - Street 1:912 S RIDGEWOOD AVE
Mailing Address - Street 2:STE. D
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:912 S RIDGEWOOD AVE
Practice Address - Street 2:STE. D
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5349
Practice Address - Country:US
Practice Address - Phone:407-496-7998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9679261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center