Healthcare Provider Details

I. General information

NPI: 1700852357
Provider Name (Legal Business Name): GULF COAST MED CTR PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11528 US HIGHWAY 19
PORT RICHEY FL
34668-1442
US

IV. Provider business mailing address

11528 US HIGHWAY 19
PORT RICHEY FL
34668-1442
US

V. Phone/Fax

Practice location:
  • Phone: 727-861-4770
  • Fax: 727-861-3351
Mailing address:
  • Phone: 727-861-4770
  • Fax: 727-861-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: LORI BRIENZA
Title or Position: FACILITIES DIRECTOR
Credential: RN, LHRM, CCS-P
Phone: 727-868-2151