Provider Demographics
NPI:1053483685
Name:COAST PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:COAST PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, ATC
Authorized Official - Phone:321-607-2454
Mailing Address - Street 1:500 N. WASHINGTON AVE
Mailing Address - Street 2:STE 107
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796
Mailing Address - Country:US
Mailing Address - Phone:321-269-0800
Mailing Address - Fax:321-383-0404
Practice Address - Street 1:500 N. WASHINGTON AVE
Practice Address - Street 2:STE 107
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796
Practice Address - Country:US
Practice Address - Phone:321-269-0800
Practice Address - Fax:321-383-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886365200Medicaid
FL886365200Medicaid