Healthcare Provider Details

I. General information

NPI: 1992738496
Provider Name (Legal Business Name): COASTAL VILLAGE PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 JAMES WAY SUITE 209
PISMO BEACH CA
93449-4976
US

IV. Provider business mailing address

PO BOX 428
GROVER BEACH CA
93483-0428
US

V. Phone/Fax

Practice location:
  • Phone: 805-773-7440
  • Fax: 805-773-7448
Mailing address:
  • Phone: 805-773-7440
  • Fax: 805-773-7448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA49080
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA70251
License Number StateCA

VIII. Authorized Official

Name: JOSEPH A. CRUZ
Title or Position: GENERAL PARTNER
Credential: MD
Phone: 805-773-7440