Provider Demographics
NPI:1982738431
Name:GULFCOAST PHYSICAL THERAPY AND PERFORMANCE CENTER INC
Entity Type:Organization
Organization Name:GULFCOAST PHYSICAL THERAPY AND PERFORMANCE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:WICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-924-8868
Mailing Address - Street 1:3568 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-8408
Mailing Address - Country:US
Mailing Address - Phone:941-924-8868
Mailing Address - Fax:
Practice Address - Street 1:3568 CLARK RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-8408
Practice Address - Country:US
Practice Address - Phone:941-924-8868
Practice Address - Fax:941-924-6670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT9887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY905ZOtherBCBS NUMBER
FLK4050Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER