MEDICARE: COASTLINE PHYSICAL THERAPY LLC

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	:	1174380422
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTLINE PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	704 HORTON ST
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32169-2920
Country	:	US
Telephone Number	:	770-235-0071
Fax Number	:

Provider Business Practice Location Address
First Line	:	3781 S NOVA RD STE B
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-4285
Country	:	US
Telephone Number	:	770-235-0071
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JOHN MINELLA
Credential	:
Telephone Number	:	770-235-0071

Provider Enumeration Date	:	03/04/2024
Last Update Date	:	03/04/2024

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