Provider Demographics
NPI:1013179597
Name:PACIFIC COAST SPINE CENTER A PHYSICAL THERAPY CORP
Entity Type:Organization
Organization Name:PACIFIC COAST SPINE CENTER A PHYSICAL THERAPY CORP
Other - Org Name:PACIFIC COAST SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:805-489-1477
Mailing Address - Street 1:880 OAK PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-1821
Mailing Address - Country:US
Mailing Address - Phone:805-489-1477
Mailing Address - Fax:805-489-2356
Practice Address - Street 1:880 OAK PARK BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-1821
Practice Address - Country:US
Practice Address - Phone:805-489-1477
Practice Address - Fax:805-489-2356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3123027225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55851OtherCITY BUSINESS LICENSE-ARROYO GRANDE, CA 93420
CAC3123027OtherCORPORATION NUMBER
CA6144720001Medicare NSC
CAC3123027OtherCORPORATION NUMBER