Provider Demographics
NPI:1962483370
Name:INTRACOASTAL PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:INTRACOASTAL PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:321-951-2416
Mailing Address - Street 1:308 S HARBOR CITY BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1500
Mailing Address - Country:US
Mailing Address - Phone:321-951-2416
Mailing Address - Fax:321-951-2077
Practice Address - Street 1:308 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1500
Practice Address - Country:US
Practice Address - Phone:321-951-2416
Practice Address - Fax:321-951-2077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
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
FLY902WOtherBLUE CROSS/BLUE SHIELD GR
FLK4415Medicare ID - Type UnspecifiedMEDICARE PROVIDER GROUP