Healthcare Provider Details

I. General information

NPI: 1922499979
Provider Name (Legal Business Name): COASTAL HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 MESA ROAD
BOLINAS CA
94924
US

IV. Provider business mailing address

PO BOX 910
POINT REYES STATION CA
94956-0910
US

V. Phone/Fax

Practice location:
  • Phone: 415-663-8666
  • Fax: 415-663-9532
Mailing address:
  • Phone: 415-663-8781
  • Fax: 415-663-9632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateCA

VIII. Authorized Official

Name: STEVEN P SIEGEL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 415-663-8781