MEDICARE: COASTAL CHIROPRACTIC PALM HARBOR LLC

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	261QM2500X	Medical Specialty Clinic/Center	CH6488	FL

General Provider Information

NPI Number	:	1679879282
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CHIROPRACTIC PALM HARBOR LLC

Provider Business Mailing Address
First Line	:	3091 ANDERSON SNOW RD
Second Line	:
City	:	SPRING HILL
State	:	FL
Zip	:	34609-5202
Country	:	US
Telephone Number	:	352-799-7753
Fax Number	:

Provider Business Practice Location Address
First Line	:	3091 ANDERSON SNOW RD
Second Line	:
City	:	SPRING HILL
State	:	FL
Zip	:	34609-5202
Country	:	US
Telephone Number	:	352-799-7753
Fax Number	:

Authorized Official
Title or Position	:	MGRM
Name	:	DR. DREW KYCYNKA
Credential	:	DC
Telephone Number	:	352-799-7753

Provider Enumeration Date	:	01/28/2011
Last Update Date	:	01/28/2011

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