Healthcare Provider Details

I. General information

NPI: 1861033466
Provider Name (Legal Business Name): BAYSIDE PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2019
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 GREENO RD N STE 102
FAIRHOPE AL
36532-2979
US

IV. Provider business mailing address

PO BOX 927
FAIRHOPE AL
36533-0927
US

V. Phone/Fax

Practice location:
  • Phone: 251-928-9954
  • Fax:
Mailing address:
  • Phone: 251-928-9954
  • Fax: 251-210-3216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT STANLEY
Title or Position: CEO
Credential:
Phone: 251-210-3210