Provider Demographics
NPI:1700658408
Name:SEASIDE PERFORMANCE PHYSICAL THERAPY, APC
Entity Type:Organization
Organization Name:SEASIDE PERFORMANCE PHYSICAL THERAPY, APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAITLIN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MIKKELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:858-717-2621
Mailing Address - Street 1:754 SNAPDRAGON ST
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-3346
Mailing Address - Country:US
Mailing Address - Phone:858-717-2621
Mailing Address - Fax:
Practice Address - Street 1:6102 AVENIDA ENCINAS STE G
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1005
Practice Address - Country:US
Practice Address - Phone:760-884-0301
Practice Address - Fax:760-560-4285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-25
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy