Provider Demographics
NPI:1306256987
Name:CORAL SPRINGS PHYSICAL MEDICINE, INC.
Entity type:Organization
Organization Name:CORAL SPRINGS PHYSICAL MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALIYAH
Authorized Official - Middle Name:
Authorized Official - Last Name:STOTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-752-7373
Mailing Address - Street 1:9858 CLINT MOORE RD
Mailing Address - Street 2:C111-274
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-1034
Mailing Address - Country:US
Mailing Address - Phone:561-482-1144
Mailing Address - Fax:561-482-1145
Practice Address - Street 1:9720 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4004
Practice Address - Country:US
Practice Address - Phone:954-752-7373
Practice Address - Fax:954-752-7351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9519208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty