Provider Demographics
NPI:1396842654
Name:PALM COAST PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:PALM COAST PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:P
Authorized Official - Last Name:CRISWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-430-0123
Mailing Address - Street 1:1056 GOODLETTE RD N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5488
Mailing Address - Country:US
Mailing Address - Phone:239-430-0123
Mailing Address - Fax:239-430-0124
Practice Address - Street 1:1056 GOODLETTE RD N
Practice Address - Street 2:SUITE 100
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5488
Practice Address - Country:US
Practice Address - Phone:239-430-0123
Practice Address - Fax:239-430-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ0412Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER