Healthcare Provider Details

I. General information

NPI: 1972251023
Provider Name (Legal Business Name): COASTAL WELLNESS AND PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 MAIN ST STE A
HALF MOON BAY CA
94019-1987
US

IV. Provider business mailing address

785 MAIN ST STE A
HALF MOON BAY CA
94019-1987
US

V. Phone/Fax

Practice location:
  • Phone: 650-712-8400
  • Fax:
Mailing address:
  • Phone: 310-424-0425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: KANCHAN PHYSICAL KHURANA
Title or Position: PRESIDENT
Credential: PT, MPT
Phone: 310-424-0425