Healthcare Provider Details

I. General information

NPI: 1922178722
Provider Name (Legal Business Name): COASTAL CAROLINA CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 VILLAGE RD SW
SHALLOTTE NC
28470-3412
US

IV. Provider business mailing address

728 VILLAGE RD SW
SHALLOTTE NC
28470-3412
US

V. Phone/Fax

Practice location:
  • Phone: 910-755-5400
  • Fax: 910-755-5402
Mailing address:
  • Phone: 910-755-5400
  • Fax: 910-755-5402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3306
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNC

VIII. Authorized Official

Name: BRIAN SALVATORE LANK
Title or Position: OWNER
Credential: D.C.
Phone: 910-755-5400