1821072067 NPI number — COASTSIDE PHYSICAL THERAPY

Table of content: (NPI 1821072067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821072067 NPI number — COASTSIDE PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTSIDE PHYSICAL THERAPY
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:
6
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:
1821072067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 612260
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95161-2260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-325-2776
Provider Business Mailing Address Fax Number:
408-945-4011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
52 AURA VISTA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PACIFICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94044-1848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-355-4558
Provider Business Practice Location Address Fax Number:
650-355-4645
Provider Enumeration Date:
12/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LASSON
Authorized Official First Name:
ANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
408-570-0510

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: ZZZ20234Z . This is a "BLUESHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 8156597 . This is a "AETNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1321715 . This is a "CIGNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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