Provider Demographics
NPI:1194771808
Name:PALM COAST SPINE AND REHAB INC
Entity type:Organization
Organization Name:PALM COAST SPINE AND REHAB INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEMCHAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-960-3775
Mailing Address - Street 1:2699 LEE RD
Mailing Address - Street 2:SUITE 505
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-1753
Mailing Address - Country:US
Mailing Address - Phone:407-960-3775
Mailing Address - Fax:407-960-3652
Practice Address - Street 1:2699 LEE RD
Practice Address - Street 2:SUITE 505
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1753
Practice Address - Country:US
Practice Address - Phone:407-960-3775
Practice Address - Fax:407-960-3652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6319410001Medicare NSC
FLK6537Medicare PIN