Provider Demographics
NPI:1760668388
Name:COLEY CHIROPRACTIC PA
Entity Type:Organization
Organization Name:COLEY CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-723-1011
Mailing Address - Street 1:635 S WICKHAM RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:W MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1436
Mailing Address - Country:US
Mailing Address - Phone:321-723-1011
Mailing Address - Fax:321-723-1110
Practice Address - Street 1:635 S WICKHAM RD
Practice Address - Street 2:SUITE 203
Practice Address - City:W MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1436
Practice Address - Country:US
Practice Address - Phone:321-723-1011
Practice Address - Fax:321-723-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty