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General NPI Number Information
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NPI Number | 1841562410
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Entity Type | Organization
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Legal Business Name | COASTAL SPINE AND SPORT, LLC
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Dates
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Enumeration Date | 01/30/2012
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Last Update Date | 01/30/2012
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Provider Practice Location Address
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Address Line | 10 CYPRESS POINT PKWY STE 106
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City | PALM COAST
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State | FL
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Zip | 32164-2503
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Country | US
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Telephone | 386-283-5997
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Fax | 386-283-5652
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Provider Business Mailing Address
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Address Line | 10 CYPRESS POINT PKWY STE 106
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City | PALM COAST
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State | FL
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Zip | 32164-2503
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Country | US
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Telephone | 386-283-5997
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Fax | 386-283-5652
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Authorized Official
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Title or Position | OWNER
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Name | DR. MICHAEL OSBORNE
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Credential | DC
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Telephone | 386-283-5997
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH9489
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License Number State | FL
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