1922038173 NPI number — COASTAL RADIATION ONCOLOGY MEDICAL GROUP, INC.

Table of content: (NPI 1922038173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922038173 NPI number — COASTAL RADIATION ONCOLOGY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL RADIATION ONCOLOGY MEDICAL GROUP, 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:
1922038173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 CASA ST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93405-1883
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-541-1932
Provider Business Mailing Address Fax Number:
831-684-7714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1213 E OCEAN AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOMPOC
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93436-7043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-736-8628
Provider Business Practice Location Address Fax Number:
805-736-8785
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RODNICK
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-648-5191

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com