Provider Demographics
NPI:1720014483
Name:GULF COAST PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:GULF COAST PHYSICAL THERAPY, INC
Other - Org Name:GULF COAST AQUATIC AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGEMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-563-0030
Mailing Address - Street 1:6043 W NORDLING LOOP
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-8716
Mailing Address - Country:US
Mailing Address - Phone:352-563-0030
Mailing Address - Fax:352-563-0102
Practice Address - Street 1:6043 W NORDLING LOOP
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-8716
Practice Address - Country:US
Practice Address - Phone:352-563-0030
Practice Address - Fax:352-563-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ99OtherBC/BS OF FLORIDA PRV #
FL10-6748Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER