Provider Demographics
NPI:1851761530
Name:COAST PT & AQUATIC REHAB LLC
Entity Type:Organization
Organization Name:COAST PT & AQUATIC REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOHEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:917-215-3784
Mailing Address - Street 1:39 E SCHILLER ST
Mailing Address - Street 2:UNIT 2E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-6162
Mailing Address - Country:US
Mailing Address - Phone:917-215-3784
Mailing Address - Fax:
Practice Address - Street 1:2641 W HARRISON ST
Practice Address - Street 2:COAST PT & AQUATIC REHAB @ QUEST
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3420
Practice Address - Country:US
Practice Address - Phone:917-215-3784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy