Basic Information
| Provider Information | |||||||||
| NPI: | 1528165123 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOLD COAST PHYSICAL THERAPY AND PHYSCIAL THERAPY ASST PLLC | ||||||||
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| OtherOrganizationName: | GOLD COAST PHYSICAL THERAPY AND SPORTS TRAINING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 755 NEW YORK AVENUE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313517676 | ||||||||
| FaxNumber: | 6313517667 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 NEW YORK AVENUE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313517676 | ||||||||
| FaxNumber: | 6313517667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BITRAN | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 6312627855 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 017191-1 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.