Provider Demographics
NPI:1538946827
Name:SISU COASTAL WELLNESS
Entity type:Organization
Organization Name:SISU COASTAL WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:DEVYN
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:CHAMPAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:805-217-3995
Mailing Address - Street 1:818 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-4547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:818 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4547
Practice Address - Country:US
Practice Address - Phone:509-435-7124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty