Healthcare Provider Details

I. General information

NPI: 1588249460
Provider Name (Legal Business Name): COTY CHESTNUT RCP, RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 ATLANTIC AVE STE 616
LONG BEACH CA
90813-3411
US

IV. Provider business mailing address

33131 MARINA VISTA DR
DANA POINT CA
92629-1104
US

V. Phone/Fax

Practice location:
  • Phone: 760-219-6632
  • Fax:
Mailing address:
  • Phone: 760-219-6632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number37747
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: