Provider Demographics
NPI:1699001685
Name:COASTAL PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:COASTAL PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:805-658-6964
Mailing Address - Street 1:5725 RALSTON ST
Mailing Address - Street 2:#103
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6053
Mailing Address - Country:US
Mailing Address - Phone:805-658-6964
Mailing Address - Fax:805-477-0370
Practice Address - Street 1:5725 RALSTON ST
Practice Address - Street 2:#103
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6053
Practice Address - Country:US
Practice Address - Phone:805-658-6964
Practice Address - Fax:805-477-0370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25537261QP2000X
CAPT26197261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15016Medicare UPIN