Provider Demographics
NPI:1679236806
Name:COASTAL PT
Entity Type:Organization
Organization Name:COASTAL PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PT
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:DUNCAN
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:850-378-2600
Mailing Address - Street 1:6021 STERLING RIVER WAY
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1534
Mailing Address - Country:US
Mailing Address - Phone:850-378-2600
Mailing Address - Fax:833-869-6437
Practice Address - Street 1:424 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:FL
Practice Address - Zip Code:32580-1774
Practice Address - Country:US
Practice Address - Phone:850-378-2600
Practice Address - Fax:833-869-6437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty