=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245007665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COAST 2 COAST SPORTS MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2023
-----------------------------------------------------
Last Update Date | 12/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 POWERLINE RD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33309-3172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-241-5134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 OXFORD DR
-----------------------------------------------------
City | ARCADIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91007-2643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-241-5134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PHYSICAL THERAPIST
-----------------------------------------------------
Name | KRISTIAN SALAZAR
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 626-241-5134
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------