Provider Demographics
NPI:1043375520
Name:COASTAL PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:COASTAL PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:541-469-7314
Mailing Address - Street 1:580 5TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-8329
Mailing Address - Country:US
Mailing Address - Phone:541-469-7314
Mailing Address - Fax:541-469-3669
Practice Address - Street 1:580 5TH ST
Practice Address - Street 2:SUITE 600
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-8329
Practice Address - Country:US
Practice Address - Phone:541-469-7314
Practice Address - Fax:541-469-3669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR136111OtherMEDICARE PTIN