Healthcare Provider Details

I. General information

NPI: 1720240872
Provider Name (Legal Business Name): COASTAL ALLERGY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 N PONDEROSA DR STE B111
CAMARILLO CA
93010-2379
US

IV. Provider business mailing address

2412 N PONDEROSA DR STE B111
CAMARILLO CA
93010-2379
US

V. Phone/Fax

Practice location:
  • Phone: 805-482-8989
  • Fax: 805-987-2855
Mailing address:
  • Phone: 805-482-8989
  • Fax: 805-987-2855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA74064
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG34328
License Number StateCA

VIII. Authorized Official

Name: LEWIS KANTER
Title or Position: PRESIDENT
Credential: MD
Phone: 805-482-8989