Provider Demographics
NPI:1740725761
Name:FLORIDA COAST CHIROPRACTIC CLINIC INCORPORATED
Entity type:Organization
Organization Name:FLORIDA COAST CHIROPRACTIC CLINIC INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TATALOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-265-1579
Mailing Address - Street 1:3821 WOODBRIAR TRAIL
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129
Mailing Address - Country:US
Mailing Address - Phone:386-265-1579
Mailing Address - Fax:386-265-1579
Practice Address - Street 1:3821 WOODBRIAR TRAIL
Practice Address - Street 2:SUITE 3
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129
Practice Address - Country:US
Practice Address - Phone:386-265-1579
Practice Address - Fax:386-265-1579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9744111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty