Healthcare Provider Details

I. General information

NPI: 1588809123
Provider Name (Legal Business Name): EASTSIDE SPEECH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10168 W SAMPLE RD
CORAL SPRINGS FL
33065-3938
US

IV. Provider business mailing address

10168 W SAMPLE RD
CORAL SPRINGS FL
33065-3938
US

V. Phone/Fax

Practice location:
  • Phone: 954-344-9004
  • Fax: 866-210-0998
Mailing address:
  • Phone: 954-344-9004
  • Fax: 866-210-0998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: KAREN JORDAN
Title or Position: VICE PRESIDENT
Credential: SLP
Phone: 954-599-4185