Provider Demographics
NPI:1770660631
Name:EAST COAST CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:EAST COAST CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-766-1255
Mailing Address - Street 1:903 SAINT ANDREWS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7194
Mailing Address - Country:US
Mailing Address - Phone:843-766-1255
Mailing Address - Fax:843-766-3157
Practice Address - Street 1:903 SAINT ANDREWS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7194
Practice Address - Country:US
Practice Address - Phone:843-766-1255
Practice Address - Fax:843-766-3157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC2109111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2109Medicaid
SC=========Medicare UPIN