Provider Demographics
NPI:1992890693
Name:FLORIDA GULFCOAST PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:FLORIDA GULFCOAST PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COOPERATING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:METRICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:239-948-2222
Mailing Address - Street 1:10011 ESTERO TOWN COMMONS PL
Mailing Address - Street 2:SUITE 101A
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-9465
Mailing Address - Country:US
Mailing Address - Phone:239-948-2222
Mailing Address - Fax:239-948-2225
Practice Address - Street 1:10011 ESTERO TOWN COMMONS PL
Practice Address - Street 2:SUITE 101A
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928
Practice Address - Country:US
Practice Address - Phone:239-948-2222
Practice Address - Fax:239-948-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0603462261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
K6950Medicare ID - Type Unspecified