Provider Demographics
NPI:1174380422
Name:COASTLINE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:COASTLINE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MINELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-235-0071
Mailing Address - Street 1:704 HORTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-2920
Mailing Address - Country:US
Mailing Address - Phone:770-235-0071
Mailing Address - Fax:
Practice Address - Street 1:3781 S NOVA RD STE B
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4285
Practice Address - Country:US
Practice Address - Phone:770-235-0071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty