Provider Demographics
NPI:1912221490
Name:COASTAL CHIROPRACTIC INC
Entity Type:Organization
Organization Name:COASTAL CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-669-4434
Mailing Address - Street 1:5 CUSHMAN ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-7202
Mailing Address - Country:US
Mailing Address - Phone:207-669-4434
Mailing Address - Fax:
Practice Address - Street 1:11 BOWOIN MILL ISLAND
Practice Address - Street 2:SUITE 130
Practice Address - City:TOPSHAM
Practice Address - State:ME
Practice Address - Zip Code:04086-0000
Practice Address - Country:US
Practice Address - Phone:207-837-6545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-26
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1267111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty