Provider Demographics
NPI:1689868036
Name:COASTAL CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:COASTAL CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-213-8787
Mailing Address - Street 1:12417 OCEAN GTWY
Mailing Address - Street 2:UNIT 2A
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842-9521
Mailing Address - Country:US
Mailing Address - Phone:410-213-8787
Mailing Address - Fax:410-213-1234
Practice Address - Street 1:12417 OCEAN GTWY
Practice Address - Street 2:UNIT 2A
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-9521
Practice Address - Country:US
Practice Address - Phone:410-213-8787
Practice Address - Fax:410-213-1234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01779111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD61990802OtherBCBS
MD887MMedicare PIN