Healthcare Provider Details

I. General information

NPI: 1598528598
Provider Name (Legal Business Name): COAST PAIN AND SPINE INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E GRAND AVE STE L2
GROVER BEACH CA
93433-5222
US

IV. Provider business mailing address

PO BOX 3129
TORRANCE CA
90510-3129
US

V. Phone/Fax

Practice location:
  • Phone: 805-710-9465
  • Fax:
Mailing address:
  • Phone: 310-792-3914
  • Fax: 855-898-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: CARLOS UNTAL
Title or Position: PARTNER
Credential:
Phone: 310-792-3914