Healthcare Provider Details

I. General information

NPI: 1740311737
Provider Name (Legal Business Name): COASTAL KIDS, A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2071 SAN JOAQUIN HILLS RD
NEWPORT BEACH CA
92660-6505
US

IV. Provider business mailing address

24422 AVENIDA DE LA CARLOTA STE 300
LAGUNA HILLS CA
92653-3628
US

V. Phone/Fax

Practice location:
  • Phone: 949-759-1720
  • Fax: 949-759-1442
Mailing address:
  • Phone: 949-599-2434
  • Fax: 949-599-2430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA56395
License Number StateCA

VIII. Authorized Official

Name: JEFFREY THOMPSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 949-448-8821