MEDICARE: COASTAL SPINE AND SPORT OF DAYTONA BEACH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	CH9679	FL

General Provider Information

NPI Number	:	1346679610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL SPINE AND SPORT OF DAYTONA BEACH

Provider Business Mailing Address
First Line	:	912 S RIDGEWOOD AVE
Second Line	:	STE. D
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-5349
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	912 S RIDGEWOOD AVE
Second Line	:	STE. D
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-5349
Country	:	US
Telephone Number	:	407-496-7998
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. CHRIS LEE WOJCIK
Credential	:	DC
Telephone Number	:	407-496-7998

Provider Enumeration Date	:	11/06/2013
Last Update Date	:	11/06/2013

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