1962807347 NPI number — COASTAL SPINE AND ORTHOPEDICS SPECIALIST, 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 1962807347 NPI number — COASTAL SPINE AND ORTHOPEDICS SPECIALIST, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL SPINE AND ORTHOPEDICS SPECIALIST, 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:
1962807347
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 OLD NEWPORT BLVD
Provider Second Line Business Mailing Address:
101
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92663-4241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-933-7012
Provider Business Mailing Address Fax Number:
949-387-3380

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 OLD NEWPORT BLVD
Provider Second Line Business Practice Location Address:
101
Provider Business Practice Location Address City Name:
NEWPORT BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92663-4241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-933-7012
Provider Business Practice Location Address Fax Number:
949-387-3380
Provider Enumeration Date:
10/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
RUBIN
Authorized Official First Name:
SONNY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
949-933-7012

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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