Provider Demographics
NPI:1376807511
Name:SPACE COAST MEDICAL, LLC
Entity Type:Organization
Organization Name:SPACE COAST MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-557-4667
Mailing Address - Street 1:4295 N US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-4822
Mailing Address - Country:US
Mailing Address - Phone:321-557-4667
Mailing Address - Fax:
Practice Address - Street 1:935 BAREFOOT BLVD
Practice Address - Street 2:BLDG 1 SUITE 2
Practice Address - City:BAREFOOT BAY
Practice Address - State:FL
Practice Address - Zip Code:32976-7620
Practice Address - Country:US
Practice Address - Phone:321-557-4667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-03
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6898208D00000X
261QP2000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty