Provider Demographics
NPI:1720497019
Name:COASTAL CAROLINA CHIROPRACTIC
Entity Type:Organization
Organization Name:COASTAL CAROLINA CHIROPRACTIC
Other - Org Name:COASTAL INTEGRATIVE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-755-5400
Mailing Address - Street 1:728 VILLAGE RD SW
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28470-3412
Mailing Address - Country:US
Mailing Address - Phone:910-755-5400
Mailing Address - Fax:910-755-5402
Practice Address - Street 1:728 VILLAGE RD SW
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-3412
Practice Address - Country:US
Practice Address - Phone:910-755-5400
Practice Address - Fax:910-755-5402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP25492251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1821190075OtherNPI
NC7211899Medicaid
S99836Medicare UPIN