Provider Demographics
NPI:1821072067
Name:COASTSIDE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:COASTSIDE PHYSICAL THERAPY
Other - Org Name:COASTSIDE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LASSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-570-0510
Mailing Address - Street 1:PO BOX 612260
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95161-2260
Mailing Address - Country:US
Mailing Address - Phone:877-325-2776
Mailing Address - Fax:408-945-4011
Practice Address - Street 1:52 AURA VISTA DR
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-1848
Practice Address - Country:US
Practice Address - Phone:650-355-4558
Practice Address - Fax:650-355-4645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2007-12-05
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
CAZZZ20234ZOtherBLUESHIELD
CA8156597OtherAETNA
CA1321715OtherCIGNA
CA00PT81381Medicare PIN