Provider Demographics
NPI:1275622029
Name:COASTAL THERAPEUTICS PA
Entity Type:Organization
Organization Name:COASTAL THERAPEUTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:843-884-4783
Mailing Address - Street 1:570 LONG POINT RD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7932
Mailing Address - Country:US
Mailing Address - Phone:843-884-4783
Mailing Address - Fax:843-884-4783
Practice Address - Street 1:570 LONG POINT RD
Practice Address - Street 2:SUITE 270
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7932
Practice Address - Country:US
Practice Address - Phone:843-884-4783
Practice Address - Fax:843-884-4783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC426572Medicare ID - Type Unspecified