Healthcare Provider Details

I. General information

NPI: 1568845543
Provider Name (Legal Business Name): COAST VALLEY WORSHIP CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 N H ST STE F
LOMPOC CA
93436-3368
US

IV. Provider business mailing address

1133 N H ST STE F
LOMPOC CA
93436-3368
US

V. Phone/Fax

Practice location:
  • Phone: 805-739-1512
  • Fax: 805-349-2855
Mailing address:
  • Phone: 805-739-1512
  • Fax: 805-349-2855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MATT HAMLIN
Title or Position: EXECUTIVE DIRECTOR
Credential: MA,
Phone: 805-739-1512