Provider Demographics
NPI:1245647007
Name:GULF COAST SPINE & SPORT, LLC
Entity type:Organization
Organization Name:GULF COAST SPINE & SPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:HILLARY
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-667-9150
Mailing Address - Street 1:6622 WILLOW PARK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-9016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6622 WILLOW PARK DR
Practice Address - Street 2:SUITE 202
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-9016
Practice Address - Country:US
Practice Address - Phone:636-667-9150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11220111NS0005X
FLCH11255111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty