Provider Demographics
NPI:1801841366
Name:COASTAL CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:COASTAL CHIROPRACTIC CENTER, LLC
Other - Org Name:COASTAL CHIROPRACTIC FAMILY WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-225-5362
Mailing Address - Street 1:5401 NETHERBY LN
Mailing Address - Street 2:STE 201
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420-7363
Mailing Address - Country:US
Mailing Address - Phone:843-225-5362
Mailing Address - Fax:843-225-5363
Practice Address - Street 1:5401 NETHERBY LN
Practice Address - Street 2:STE 201
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7363
Practice Address - Country:US
Practice Address - Phone:843-225-5362
Practice Address - Fax:843-225-5363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC3074111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty