1275735011 NPI number — COASTAL COMMUNITIES PHYSICIAN NETWORK, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275735011 NPI number — COASTAL COMMUNITIES PHYSICIAN NETWORK, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL COMMUNITIES PHYSICIAN NETWORK, 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:
Provider Other Organization Name Type Code:
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:
1275735011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4580 CALIFORNIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKERSFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93309-1104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-549-0677
Provider Business Mailing Address Fax Number:
805-549-7588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 CASA ST STE 170
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93405-1887
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-549-0677
Provider Business Practice Location Address Fax Number:
805-549-7588
Provider Enumeration Date:
06/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
JU HUAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
661-327-4411

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  30221170 , 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)





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