MEDICARE: INTERCOASTAL CHIROPRACTIC CLINIC PA

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	111N00000X	Chiropractor	CH0007521	FL

General Provider Information

NPI Number	:	1457538266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERCOASTAL CHIROPRACTIC CLINIC PA

Provider Business Mailing Address
First Line	:	14255 BEACH BLVD STE A
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-1545
Country	:	US
Telephone Number	:	904-223-1616
Fax Number	:

Provider Business Practice Location Address
First Line	:	14255 BEACH BLVD STE A
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-1545
Country	:	US
Telephone Number	:	904-223-1616
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	JOYCE TUCKER
Credential	:
Telephone Number	:	904-272-3440

Provider Enumeration Date	:	01/23/2008
Last Update Date	:	08/04/2010

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Directions to “INTERCOASTAL CHIROPRACTIC CLINIC PA ” Practice Location

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