Healthcare Provider Details

I. General information

NPI: 1912692567
Provider Name (Legal Business Name): COASTLINE FAMILY CHIROPRACTIC MELBOURNE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3980 SARNO RD SUITE 102
MELBOURNE FL
32934
US

IV. Provider business mailing address

3980 SARNO RD SUITE 102
MELBOURNE FL
32934
US

V. Phone/Fax

Practice location:
  • Phone: 321-610-3000
  • Fax:
Mailing address:
  • Phone: 321-610-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KEITH RYAN HURLEY
Title or Position: AO
Credential: DC
Phone: 321-610-3000