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General NPI Number Information
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NPI Number | 1346679610
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Entity Type | Organization
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Legal Business Name | COASTAL SPINE AND SPORT OF DAYTONA BEACH
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Dates
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Enumeration Date | 11/06/2013
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Last Update Date | 11/06/2013
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Provider Practice Location Address
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Address Line | 912 S RIDGEWOOD AVE STE. D
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City | DAYTONA BEACH
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State | FL
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Zip | 32114-5349
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Country | US
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Telephone | 407-496-7998
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Fax |
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Provider Business Mailing Address
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Address Line | 912 S RIDGEWOOD AVE STE. D
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City | DAYTONA BEACH
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State | FL
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Zip | 32114-5349
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. CHRIS LEE WOJCIK
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Credential | DC
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Telephone | 407-496-7998
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | CH9679
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License Number State | FL
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