Healthcare Provider Details

I. General information

NPI: 1841164167
Provider Name (Legal Business Name): COASTAL DIABETES CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

486 CONSTITUTION AVE
CAMARILLO CA
93012-8529
US

IV. Provider business mailing address

486 CONSTITUTION AVE
CAMARILLO CA
93012-8529
US

V. Phone/Fax

Practice location:
  • Phone: 949-266-4103
  • Fax:
Mailing address:
  • Phone: 949-266-4103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CASSIDY ROBINSON
Title or Position: OWNER OPERATOR
Credential: BSN-RN, CDCES
Phone: 949-266-4103