Healthcare Provider Details

I. General information

NPI: 1942361522
Provider Name (Legal Business Name): COASTAL ORTHOPEDICS AND SPORTS MEDICINE OF SOUTHWEST FLORIDA P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 STATE ROAD 64 E
BRADENTON FL
34212-7703
US

IV. Provider business mailing address

8000 STATE ROAD 64 E
BRADENTON FL
34212-7703
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-1404
  • Fax: 941-794-1863
Mailing address:
  • Phone: 941-792-1404
  • Fax: 941-794-1863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: NANCY R BORGGREN
Title or Position: CREDENTIALING SURPERVISOR
Credential:
Phone: 941-782-0102