Healthcare Provider Details

I. General information

NPI: 1093766677
Provider Name (Legal Business Name): COASTAL FAMILY MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18785 BROOKHURST ST STE 200
FOUNTAIN VALLEY CA
92708-7300
US

IV. Provider business mailing address

PO BOX 2218
SUISUN CITY CA
94585-5218
US

V. Phone/Fax

Practice location:
  • Phone: 714-378-5330
  • Fax: 714-378-5320
Mailing address:
  • Phone: 657-241-3600
  • Fax: 657-241-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID S KIM
Title or Position: PRESIDENT
Credential: MD
Phone: 657-241-3500