Provider Demographics
NPI:1992395552
Name:COASTAL CONNECTION CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:COASTAL CONNECTION CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-251-9526
Mailing Address - Street 1:800 25TH AVE S STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-4320
Mailing Address - Country:US
Mailing Address - Phone:843-251-9526
Mailing Address - Fax:
Practice Address - Street 1:800 25TH AVE S STE A
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-4320
Practice Address - Country:US
Practice Address - Phone:843-251-9526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty