Provider Demographics
NPI:1497837488
Name:GULF COAST PHYSICAL THERAPY CENTERS PA
Entity Type:Organization
Organization Name:GULF COAST PHYSICAL THERAPY CENTERS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:ACKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:228-822-9066
Mailing Address - Street 1:PO BOX 3238
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-3238
Mailing Address - Country:US
Mailing Address - Phone:228-822-9066
Mailing Address - Fax:228-822-9722
Practice Address - Street 1:9471 THREE RIVERS RD
Practice Address - Street 2:UNIT D
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4230
Practice Address - Country:US
Practice Address - Phone:228-822-9066
Practice Address - Fax:228-822-9722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015748Medicaid
MS09015748Medicaid