Basic Information
| Provider Information | |||||||||
| NPI: | 1982946810 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL REHAB AND SPORTS MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 PALM COAST PKWY NE | ||||||||
| Address2: | |||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321373805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864464101 | ||||||||
| FaxNumber: | 3864472161 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 PALM COAST PKWY NE | ||||||||
| Address2: | |||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321373805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864464101 | ||||||||
| FaxNumber: | 3864472161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2013 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | SIBILLE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9045014344 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | PT21524 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.