Provider Demographics
NPI:1780840132
Name:COASTAL CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:COASTAL CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:912-351-0875
Mailing Address - Street 1:7370 HODGSON MEMORIAL DR
Mailing Address - Street 2:STE E3
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2536
Mailing Address - Country:US
Mailing Address - Phone:912-351-0875
Mailing Address - Fax:
Practice Address - Street 1:7370 HODGSON MEMORIAL DR
Practice Address - Street 2:STE E3
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2536
Practice Address - Country:US
Practice Address - Phone:912-351-0875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002514111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCBCBOtherMEDICARE IDENTIFICATION NUMBER