Provider Demographics
NPI:1548712656
Name:COASTAL SPINE AND SPORT, LLC
Entity type:Organization
Organization Name:COASTAL SPINE AND SPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOLDIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-540-1270
Mailing Address - Street 1:179 WILLOWBEND LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8446
Mailing Address - Country:US
Mailing Address - Phone:843-540-1270
Mailing Address - Fax:
Practice Address - Street 1:7509 NORTHSIDE DR
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-4211
Practice Address - Country:US
Practice Address - Phone:843-540-1270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2745111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty