Provider Demographics
NPI:1609215169
Name:COASTAL CHIROPRACTIC PALM HARBOR LLC
Entity Type:Organization
Organization Name:COASTAL CHIROPRACTIC PALM HARBOR LLC
Other - Org Name:COASTAL CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
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 1:2196 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-5650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2196 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-5650
Practice Address - Country:US
Practice Address - Phone:727-733-1601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 6488111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty