Provider Demographics
NPI:1841562410
Name:COASTAL SPINE AND SPORT, LLC
Entity Type:Organization
Organization Name:COASTAL SPINE AND SPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-283-5997
Mailing Address - Street 1:10 CYPRESS POINT PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-2503
Mailing Address - Country:US
Mailing Address - Phone:386-283-5997
Mailing Address - Fax:386-283-5652
Practice Address - Street 1:10 CYPRESS POINT PKWY STE 106
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2503
Practice Address - Country:US
Practice Address - Phone:386-283-5997
Practice Address - Fax:386-283-5652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9489111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty