Healthcare Provider Details

I. General information

NPI: 1902267644
Provider Name (Legal Business Name): COASTAL CHILDREN'S SPECIALTY GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 LONG BEACH BLVD SUITE 177
LONG BEACH CA
90806-1596
US

IV. Provider business mailing address

2850 LONG BEACH BLVD SUITE 177
LONG BEACH CA
90806-1596
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-8750
  • Fax: 562-933-8014
Mailing address:
  • Phone: 562-933-8750
  • Fax: 562-933-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TORIN J. CUNNINGHAM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 562-933-8750