MEDICARE: COASTSIDE PHYSICAL THERAPY

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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ20234Z	OTHER	CA	BLUESHIELD
2	1321715	OTHER	CA	CIGNA
3	8156597	OTHER	CA	AETNA

General Provider Information

NPI Number	:	1811971674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTSIDE PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	PO BOX 612260
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95161-2260
Country	:	US
Telephone Number	:	877-325-2776
Fax Number	:	408-945-4011

Provider Business Practice Location Address
First Line	:	799 MAIN ST
Second Line	:	SUITE D
City	:	HALF MOON BAY
State	:	CA
Zip	:	94019-1996
Country	:	US
Telephone Number	:	650-726-6378
Fax Number	:	650-726-6389

Authorized Official
Title or Position	:	VICE PRESDENT
Name	:	ANNE LASSON
Credential	:
Telephone Number	:	408-570-0510

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	10/08/2007

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Directions to “COASTSIDE PHYSICAL THERAPY ” Practice Location

Language	Start Address	Practice Location

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