Provider Demographics
NPI:1861565806
Name:SOUTH COAST PHYSICAL THERAPY
Entity type:Organization
Organization Name:SOUTH COAST PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SOAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SALAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:714-842-6171
Mailing Address - Street 1:17752 BEACH BLVD
Mailing Address - Street 2:#306
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646
Mailing Address - Country:US
Mailing Address - Phone:714-842-6171
Mailing Address - Fax:714-842-0281
Practice Address - Street 1:5750 DOWNEY AVE
Practice Address - Street 2:#301
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712
Practice Address - Country:US
Practice Address - Phone:562-633-3501
Practice Address - Fax:562-633-6178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16314Medicare ID - Type Unspecified