Basic Information
| Provider Information | |||||||||
| NPI: | 1518026921 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL REHAB, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5703 GULF TECH DR | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395648200 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 5703 GULF TECH DR | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395648200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288755447 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | AULTMAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 2288755447 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.