Healthcare Provider Details

I. General information

NPI: 1720659154
Provider Name (Legal Business Name): COQUINA SPORT & SPINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 US 1 S STE B
ST AUGUSTINE FL
32086-6311
US

IV. Provider business mailing address

2820 US 1 S STE B
ST AUGUSTINE FL
32086-6311
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-3232
  • Fax:
Mailing address:
  • Phone: 904-797-3232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTIN WIMP
Title or Position: OWNER
Credential: DC, ATC
Phone: 904-797-3232