Provider Demographics
NPI:1285609560
Name:COASTAL PHYSICAL THERAPY
Entity type:Organization
Organization Name:COASTAL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:POULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-799-4199
Mailing Address - Street 1:3114 RANDALL PKWY STE 2
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2590
Mailing Address - Country:US
Mailing Address - Phone:910-799-4199
Mailing Address - Fax:910-799-1616
Practice Address - Street 1:3114 RANDALL PKWY STE 2
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2590
Practice Address - Country:US
Practice Address - Phone:910-799-4199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7210529Medicaid
NC0238QOtherBLUE CROSS BLUE SHIELD
NC=========Medicare UPIN
NC0238QOtherBLUE CROSS BLUE SHIELD