Healthcare Provider Details

I. General information

NPI: 1245647007
Provider Name (Legal Business Name): GULF COAST SPINE & SPORT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6622 WILLOW PARK DR SUITE 202
NAPLES FL
34109-9016
US

IV. Provider business mailing address

6622 WILLOW PARK DR SUITE 202
NAPLES FL
34109-9016
US

V. Phone/Fax

Practice location:
  • Phone: 636-667-9150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCH11220
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH11255
License Number StateFL

VIII. Authorized Official

Name: HILLARY YOUNG
Title or Position: CHIROPRACTIC PHYSICIAN
Credential: D.C.
Phone: 636-667-9150