Provider Demographics
NPI:1356334718
Name:SPACE COAST CORPORATE HEALTH SERVICE P A
Entity type:Organization
Organization Name:SPACE COAST CORPORATE HEALTH SERVICE P A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JE
Authorized Official - Last Name:CLOW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-725-8778
Mailing Address - Street 1:145 PALM BAY RD NE
Mailing Address - Street 2:STE 120
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-8601
Mailing Address - Country:US
Mailing Address - Phone:321-725-8778
Mailing Address - Fax:321-984-5299
Practice Address - Street 1:145 PALM BAY RD NE
Practice Address - Street 2:STE 120
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-8601
Practice Address - Country:US
Practice Address - Phone:321-725-8778
Practice Address - Fax:321-984-5299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4422111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34121OtherBCBS
FLK2837Medicare PIN