MEDICARE: BEACHSIDE 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	162869100	OTHER	FL	US DOL GROUP ID
2	Y912G	OTHER	FL	BCBS GROUP ID

General Provider Information

NPI Number	:	1699713222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACHSIDE PHYSICAL THERAPY, INC

Provider Business Mailing Address
First Line	:	660 E EAU GALLIE BLVD STE 106
Second Line	:
City	:	INDIAN HARBOUR BEACH
State	:	FL
Zip	:	32937-4252
Country	:	US
Telephone Number	:	321-773-5290
Fax Number	:	321-773-5268

Provider Business Practice Location Address
First Line	:	3680 N WICKHAM RD
Second Line	:	STE B
City	:	MELBOURNE
State	:	FL
Zip	:	32935-2327
Country	:	US
Telephone Number	:	321-255-5500
Fax Number	:	321-255-5551

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	GABRIELA LITT
Credential	:
Telephone Number	:	951-696-9353

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	04/20/2021

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