Provider Demographics
NPI:1962489310
Name:AMED-COASTAL THERAPISTS, INC
Entity Type:Organization
Organization Name:AMED-COASTAL THERAPISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:F
Authorized Official - Last Name:CROWDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-935-1234
Mailing Address - Street 1:8900 EMMETT F LOWRY EXPY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TEXAS CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77591-9116
Mailing Address - Country:US
Mailing Address - Phone:409-935-7925
Mailing Address - Fax:409-935-7926
Practice Address - Street 1:6501 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-4015
Practice Address - Country:US
Practice Address - Phone:409-935-1393
Practice Address - Fax:409-935-3844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX617670000261QR0400X
TX520220000261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX021732501Medicaid
TX0076AWOtherBLUE CROSS BLUE SHIELD
TX456823Medicare ID - Type Unspecified