Basic Information
| Provider Information | |||||||||
| NPI: | 1699713222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEACHSIDE PHYSICAL THERAPY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 E EAU GALLIE BLVD STE 106 | ||||||||
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| City: | INDIAN HARBOUR BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329374252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217735290 | ||||||||
| FaxNumber: | 3217735268 | ||||||||
| Practice Location | |||||||||
| Address1: | 3680 N WICKHAM RD | ||||||||
| Address2: | STE B | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329352327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212555500 | ||||||||
| FaxNumber: | 3212555551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | LITT | ||||||||
| AuthorizedOfficialFirstName: | GABRIELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9516969353 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 162869100 | 01 | FL | US DOL GROUP ID | OTHER | Y912G | 01 | FL | BCBS GROUP ID | OTHER |