Basic Information
| Provider Information | |||||||||
| NPI: | 1033241302 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOLD COAST PHYSICAL THERAPIST AND PHYSICAL THERAPY ASSISTANT PLLC | ||||||||
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| OtherOrganizationName: | GOLD COAST PHYSICAL THERAPY AND SPORTS TRAININ | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5036 JERICHO TPKE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | COMMACK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117252812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314865286 | ||||||||
| FaxNumber: | 6314865287 | ||||||||
| Practice Location | |||||||||
| Address1: | 5036 JERICHO TPKE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | COMMACK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117252812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314865286 | ||||||||
| FaxNumber: | 6314865287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GERACI | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6314865286 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.