Provider Demographics
NPI:1962100180
Name:COASTAL SPECIALTY PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:COASTAL SPECIALTY PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZELTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:858-353-7702
Mailing Address - Street 1:12625 HIGH BLUFF DR STE 107
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2053
Mailing Address - Country:US
Mailing Address - Phone:858-353-7702
Mailing Address - Fax:
Practice Address - Street 1:12625 HIGH BLUFF DR STE 107
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2053
Practice Address - Country:US
Practice Address - Phone:858-353-7702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-16
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty