Provider Demographics
NPI:1497930382
Name:GOLD COAST CHIROPRACTIC & REHAB P A
Entity Type:Organization
Organization Name:GOLD COAST CHIROPRACTIC & REHAB P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-542-7660
Mailing Address - Street 1:4210 DEL PRADO BLVD S
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-7166
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4210 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-7166
Practice Address - Country:US
Practice Address - Phone:239-542-7660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDE1877OtherRAILRAOD MEDICARE PART B GROUP NUMBER
FLP00277193OtherRAILROAD MEDICARE PART B PTAN
FLDE1877OtherRAILRAOD MEDICARE PART B GROUP NUMBER