Healthcare Provider Details

I. General information

NPI: 1992160816
Provider Name (Legal Business Name): COASTAL CHIROPRACTIC AND ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2015
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E JIMMIE LEEDS RD
GALLOWAY NJ
08205-9508
US

IV. Provider business mailing address

106 E JIMMIE LEEDS RD
GALLOWAY NJ
08205-9508
US

V. Phone/Fax

Practice location:
  • Phone: 609-748-8779
  • Fax: 609-652-6687
Mailing address:
  • Phone: 609-748-8779
  • Fax: 609-652-6687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00600700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00032700
License Number StateNJ

VIII. Authorized Official

Name: DR. FRED CHANG
Title or Position: OWNER
Credential: DC, L. AC
Phone: 609-748-8779