1912925371 NPI number — COASTAL CHIROPRACTIC CENTER PA

Table of content: (NPI 1912925371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912925371 NPI number — COASTAL CHIROPRACTIC CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL CHIROPRACTIC CENTER PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912925371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12027
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28405-0100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-343-1111
Provider Business Mailing Address Fax Number:
910-343-8292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3825 MARKET ST
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28403-1453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-343-1111
Provider Business Practice Location Address Fax Number:
910-343-8292
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VANCAMPEN
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
ADRIAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-343-1111

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8908304 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08304 . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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