Provider Demographics
NPI:1134593759
Name:COASTAL SPINE & WELLNESS FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:COASTAL SPINE & WELLNESS FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-352-2192
Mailing Address - Street 1:3070 N HIGHWAY 17
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-9300
Mailing Address - Country:US
Mailing Address - Phone:843-352-2180
Mailing Address - Fax:843-352-2192
Practice Address - Street 1:3070 N HIGHWAY 17
Practice Address - Street 2:SUITE 200
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-9300
Practice Address - Country:US
Practice Address - Phone:843-352-2180
Practice Address - Fax:843-352-2192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4043111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty