Healthcare Provider Details

I. General information

NPI: 1508916628
Provider Name (Legal Business Name): COASTSIDE FAMILY MEDICAL CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CABRILLO HWY S STE 100A
HALF MOON BAY CA
94019-1738
US

IV. Provider business mailing address

225 CABRILLO HWY S STE 100A
HALF MOON BAY CA
94019-1738
US

V. Phone/Fax

Practice location:
  • Phone: 650-712-7330
  • Fax: 650-726-9317
Mailing address:
  • Phone: 650-712-7330
  • Fax: 650-726-9317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT V HARLESS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 650-712-7330