MEDICARE: COAST TO COAST 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	261QM1300X	Multi-Specialty Clinic/Center		CA

General Provider Information

NPI Number	:	1063859460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COAST TO COAST THERAPY INC.

Provider Business Mailing Address
First Line	:	3980 9TH AVE # 1
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-3244
Country	:	US
Telephone Number	:	619-618-9638
Fax Number	:

Provider Business Practice Location Address
First Line	:	3980 9TH AVE # 1
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-3244
Country	:	US
Telephone Number	:	619-618-9638
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	STEVEN PERUNOVICH
Credential	:	OTR/L
Telephone Number	:	619-618-9638

Provider Enumeration Date	:	05/28/2013
Last Update Date	:	05/28/2013

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