Provider Demographics
NPI:1659591568
Name:COBURN A. MARSTON, PT
Entity Type:Organization
Organization Name:COBURN A. MARSTON, PT
Other - Org Name:MAGNOLIA PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:COBURN
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:MARSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:352-787-3609
Mailing Address - Street 1:101 S 11TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5767
Mailing Address - Country:US
Mailing Address - Phone:352-787-3609
Mailing Address - Fax:352-314-8979
Practice Address - Street 1:101 S 11TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5767
Practice Address - Country:US
Practice Address - Phone:352-787-3609
Practice Address - Fax:352-314-8979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT1647261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0659Medicare ID - Type UnspecifiedGROUP PRACTICE NUMBER