Provider Demographics
NPI:1518319821
Name:COASTAL CHIROPRACTIC TAMPA BAY LLC
Entity Type:Organization
Organization Name:COASTAL CHIROPRACTIC TAMPA BAY LLC
Other - Org Name:COASTAL CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KYCYNKA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-733-1601
Mailing Address - Street 1:2194 MAIN ST STE G
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-5656
Mailing Address - Country:US
Mailing Address - Phone:727-733-1601
Mailing Address - Fax:
Practice Address - Street 1:2194 MAIN ST STE G
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-5656
Practice Address - Country:US
Practice Address - Phone:352-650-3756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6488111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty