Basic Information
Provider Information | |||||||||
NPI: | 1952415622 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEACHSIDE PHYSICAL THERAPY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 660 E EAU GALLIE BLVD STE 106 | ||||||||
Address2: |   | ||||||||
City: | INDIAN HARBOUR BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 329374252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3217735290 | ||||||||
FaxNumber: | 3217735268 | ||||||||
Practice Location | |||||||||
Address1: | 7341 OFFICE PARK PL STE 102 | ||||||||
Address2: |   | ||||||||
City: | VIERA | ||||||||
State: | FL | ||||||||
PostalCode: | 329408280 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3216906612 | ||||||||
FaxNumber: | 3214190334 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2006 | ||||||||
LastUpdateDate: | 04/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LITT | ||||||||
AuthorizedOfficialFirstName: | GABRIELA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 9516969353 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/20/2021 |
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 |   |
ID Information
ID | Type | State | Issuer | Description | 1952415622 | 01 | FL | NPI | OTHER | CK5288 | 01 | FL | MEDICARE RAILROAD | OTHER | Y923Z | 01 | FL | BC/BS GROUP NUMBER | OTHER |