MEDICARE: COASTLINE PHYSICAL THERAPY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1043935638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTLINE PHYSICAL THERAPY, INC

Provider Business Mailing Address
First Line	:	4130 N VIKING WAY STE 100
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1408
Country	:	US
Telephone Number	:	562-304-9916
Fax Number	:

Provider Business Practice Location Address
First Line	:	4130 N VIKING WAY STE 100
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1408
Country	:	US
Telephone Number	:	562-304-9916
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MARY SHANNON LUDLOFF
Credential	:	PT
Telephone Number	:	562-304-9916

Provider Enumeration Date	:	10/06/2022
Last Update Date	:	10/06/2022

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