Basic Information
| Provider Information | |||||||||
| NPI: | 1700852357 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST MED CTR PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11528 US HIGHWAY 19 | ||||||||
| Address2: | |||||||||
| City: | PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346681442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278614770 | ||||||||
| FaxNumber: | 7278613351 | ||||||||
| Practice Location | |||||||||
| Address1: | 11528 US HIGHWAY 19 | ||||||||
| Address2: | |||||||||
| City: | PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346681442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278614770 | ||||||||
| FaxNumber: | 7278613351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | BRIENZA | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | FACILITIES DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7278682151 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN, LHRM, CCS-P | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 01589 | 01 | FL | UNIVERSAL HEALTH CARE | OTHER | DE6703 | 01 | FL | RAILROAD MEDICARE | OTHER |