Provider Demographics
NPI:1932376555
Name:PALM COAST SPORTS MEDICINE AND REHAB
Entity Type:Organization
Organization Name:PALM COAST SPORTS MEDICINE AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNN
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:386-445-5555
Mailing Address - Street 1:35 OLD KINGS RD N
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8227
Mailing Address - Country:US
Mailing Address - Phone:386-445-5555
Mailing Address - Fax:386-445-9800
Practice Address - Street 1:35 OLD KINGS RD N
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8227
Practice Address - Country:US
Practice Address - Phone:386-445-5555
Practice Address - Fax:386-445-9800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0010163225100000X
FL4154225100000X
FL1549225X00000X
FLSA6443235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106943Medicare Oscar/Certification