1295902450 NPI number — BEACHSIDE PHYSICAL THERAPY INC

Table of content: (NPI 1295902450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295902450 NPI number — BEACHSIDE PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACHSIDE PHYSICAL THERAPY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295902450
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
660 E EAU GALLIE BLVD SUITE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIAN HARBOUR BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32937-4400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-773-5290
Provider Business Mailing Address Fax Number:
321-773-5268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4270 MINTON RD
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
WEST MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32904-9578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-984-2933
Provider Business Practice Location Address Fax Number:
321-953-5379
Provider Enumeration Date:
05/15/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LITT
Authorized Official First Name:
GABRIELA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
951-696-9353

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CK5288 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y931E . This is a "BC/BS GROUP NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".