Healthcare Provider Details

I. General information

NPI: 1275768194
Provider Name (Legal Business Name): COASTAL PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18990 PERSIMMON RIDGE RD
ALVA FL
33920-3367
US

IV. Provider business mailing address

PO BOX 62095
FORT MYERS FL
33906-2095
US

V. Phone/Fax

Practice location:
  • Phone: 941-681-0278
  • Fax: 239-236-0217
Mailing address:
  • Phone: 941-681-0278
  • Fax: 239-236-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT23483
License Number StateFL

VIII. Authorized Official

Name: VANESSA RACHEL MARTIN
Title or Position: PRESIDENT
Credential: MSPT
Phone: 19416810278