Healthcare Provider Details

I. General information

NPI: 1316612575
Provider Name (Legal Business Name): COASTAL P&O LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26300 LA ALAMEDA STE 120
MISSION VIEJO CA
92691-6380
US

IV. Provider business mailing address

18 BUSHWOOD CIR
LADERA RANCH CA
92694-0513
US

V. Phone/Fax

Practice location:
  • Phone: 714-614-5981
  • Fax:
Mailing address:
  • Phone: 714-614-5981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name: MR. CHAD MARQUIS
Title or Position: CERTIFIED PROSTHETIST/ORTHOTIST
Credential: CPO
Phone: 714-614-5981