Healthcare Provider Details

I. General information

NPI: 1376807511
Provider Name (Legal Business Name): SPACE COAST MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 BAREFOOT BLVD BLDG 1 SUITE 2
BAREFOOT BAY FL
32976-7620
US

IV. Provider business mailing address

4295 N US HIGHWAY 1
MELBOURNE FL
32935-4822
US

V. Phone/Fax

Practice location:
  • Phone: 321-557-4667
  • Fax:
Mailing address:
  • Phone: 321-557-4667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS6898
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JASON LAIL
Title or Position: C.E.O.
Credential:
Phone: 321-557-4667