Healthcare Provider Details

I. General information

NPI: 1407974967
Provider Name (Legal Business Name): COAST PULMONARY & INTERNAL MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9940 TALBERT AVE SUITE 101
FOUNTAIN VALLEY CA
92708-5153
US

IV. Provider business mailing address

9940 TALBERT AVE SUITE 101
FOUNTAIN VALLEY CA
92708-5153
US

V. Phone/Fax

Practice location:
  • Phone: 714-545-8700
  • Fax: 714-545-8084
Mailing address:
  • Phone: 714-545-8700
  • Fax: 714-545-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA75677
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA37535
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberG26245
License Number StateCA

VIII. Authorized Official

Name: MRS. JILL ROELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 714-545-8700