Provider Demographics
NPI:1598847899
Name:GOLD COAST PHYSICAL THERAPY ASSOCIATES LLC
Entity Type:Organization
Organization Name:GOLD COAST PHYSICAL THERAPY ASSOCIATES LLC
Other - Org Name:FYZICAL THERAPY & BALANCE CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:561-432-0111
Mailing Address - Street 1:5840 CORPORATE WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2040
Mailing Address - Country:US
Mailing Address - Phone:561-432-0111
Mailing Address - Fax:561-432-1075
Practice Address - Street 1:6169 JOG RD
Practice Address - Street 2:SUITE A11
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467
Practice Address - Country:US
Practice Address - Phone:561-432-0111
Practice Address - Fax:561-432-1075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891951800Medicaid
FL6699392OtherGHI
FLY918ZOtherBCBS
FL4670650001Medicare NSC
FLK2416Medicare UPIN