1992738496 NPI number — COASTAL VILLAGE PRIMARY CARE

Table of content: (NPI 1992738496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992738496 NPI number — COASTAL VILLAGE PRIMARY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL VILLAGE PRIMARY CARE
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:
1992738496
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROVER BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93483-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-773-7440
Provider Business Mailing Address Fax Number:
805-773-7448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 JAMES WAY
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
PISMO BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93449-4976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-773-7440
Provider Business Practice Location Address Fax Number:
805-773-7448
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRUZ
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
GENERAL PARTNER
Authorized Official Telephone Number:
805-773-7440

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A49080 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: A70251 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ZZZ06670Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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