MEDICARE: COASTAL CHIROPRACTIC CENTER, 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	111N00000X	Chiropractor	SC3074	SC

General Provider Information

NPI Number	:	1801841366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CHIROPRACTIC CENTER, LLC

Provider Business Mailing Address
First Line	:	5401 NETHERBY LN
Second Line	:	STE 201
City	:	N CHARLESTON
State	:	SC
Zip	:	29420-7363
Country	:	US
Telephone Number	:	843-225-5362
Fax Number	:	843-225-5363

Provider Business Practice Location Address
First Line	:	5401 NETHERBY LN
Second Line	:	STE 201
City	:	N CHARLESTON
State	:	SC
Zip	:	29420-7363
Country	:	US
Telephone Number	:	843-225-5362
Fax Number	:	843-225-5363

Authorized Official
Title or Position	:	OWNER/MEMBER
Name	:	DR. RACHELLE A LARSEN
Credential	:	D.C.
Telephone Number	:	843-225-5362

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	01/10/2008

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