Provider Demographics
NPI:1619900644
Name:COAST VILLAGE PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:COAST VILLAGE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:W
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:805-565-5670
Mailing Address - Street 1:1122 COAST VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93108-2711
Mailing Address - Country:US
Mailing Address - Phone:805-565-5670
Mailing Address - Fax:805-565-5690
Practice Address - Street 1:1122 COAST VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93108-2711
Practice Address - Country:US
Practice Address - Phone:805-565-5670
Practice Address - Fax:805-565-5690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26913261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18428Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER