1003953241 NPI number — GOLD COAST MEDICAL SERVICES INC

Table of content: (NPI 1003953241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003953241 NPI number — GOLD COAST MEDICAL SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLD COAST MEDICAL SERVICES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GOLD COAST MEDICAL SERVICES, INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003953241
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1551 NURSERY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCKINLEYVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95519-3982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-633-6183
Provider Business Mailing Address Fax Number:
707-633-6184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1551 NURSERY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCKINLEYVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95519-3982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-633-6183
Provider Business Practice Location Address Fax Number:
707-633-6184
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WADSWORTH
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
707-443-2907

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY42086 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PHA420860 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0538629 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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