=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851761530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COAST PT & AQUATIC REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2015
-----------------------------------------------------
Last Update Date | 10/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2641 W HARRISON ST COAST PT & AQUATIC REHAB @ QUEST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-215-3784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 E SCHILLER ST UNIT 2E
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-6162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-215-3784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, CLINICAL OPERATIONS
-----------------------------------------------------
Name | GERALDINE A MOHEN
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 917-215-3784
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------