Provider Demographics
NPI:1104358365
Name:COASTLINE PHYSICAL THERAPY & PERFORMANCE
Entity Type:Organization
Organization Name:COASTLINE PHYSICAL THERAPY & PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOLLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, OCS, SCS
Authorized Official - Phone:207-745-1292
Mailing Address - Street 1:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:DEER ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04627-0604
Mailing Address - Country:US
Mailing Address - Phone:207-745-1292
Mailing Address - Fax:
Practice Address - Street 1:444 DUNHAM POINT RD
Practice Address - Street 2:
Practice Address - City:DEER ISLE
Practice Address - State:ME
Practice Address - Zip Code:04627
Practice Address - Country:US
Practice Address - Phone:207-745-1292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT48162251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty