Provider Demographics
NPI:1952673766
Name:COASTAL SPINE AND REHAB CENTER LLC
Entity Type:Organization
Organization Name:COASTAL SPINE AND REHAB CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-862-3509
Mailing Address - Street 1:13910 FIVAY RD
Mailing Address - Street 2:STE. 10
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-7154
Mailing Address - Country:US
Mailing Address - Phone:727-862-3509
Mailing Address - Fax:727-862-3500
Practice Address - Street 1:13910 FIVAY RD
Practice Address - Street 2:STE 10
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7154
Practice Address - Country:US
Practice Address - Phone:727-862-3509
Practice Address - Fax:727-862-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 10521111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty