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Organization
SPACE COAST MEDICAL, LLC
Active
Organization
SPACE COAST MEDICAL, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JASON LAIL (C.E.O.)
(321) 557-4667
Entity
Organization
Contact information
Practice address
935 BAREFOOT BLVD, BLDG 1 SUITE 2, BAREFOOT BAY, FL 32976-7620
(321) 557-4667
Mailing address
4295 N US HIGHWAY 1, MELBOURNE, FL 32935-4822
(321) 557-4667
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
OS6898
FL
261QP2000X
Physical Therapy Clinic/Center
—
—
261QR0400X
Rehabilitation Clinic/Center
Primary
—
—
Other
Enumeration date
07/03/2012
Last updated
07/28/2015
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