Basic Information
| Provider Information | |||||||||
| NPI: | 1770124000 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST REHAB THERAPY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7651 SW HIGHWAY 200 STE 206 | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344767727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7279922039 | ||||||||
| FaxNumber: | 7278683838 | ||||||||
| Practice Location | |||||||||
| Address1: | 7651 SW HIGHWAY 200 STE 206 | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344767727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7279922039 | ||||||||
| FaxNumber: | 7278683838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2019 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | OUANO | ||||||||
| AuthorizedOfficialFirstName: | MAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7279922039 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 10/26/2020 | ||||||||
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 | PT773 | 01 | FL | MEDICAL LICENSE | OTHER |