Healthcare Provider Details

I. General information

NPI: 1699956839
Provider Name (Legal Business Name): COASTAL HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 THIRD STREET, SUITE 17
POINT REYES STATION CA
94956-0910
US

IV. Provider business mailing address

PO BOX 910 65 THIRD STREET, SUITE 17
POINT REYES STATION CA
94956-0910
US

V. Phone/Fax

Practice location:
  • Phone: 415-663-8781
  • Fax: 415-663-9630
Mailing address:
  • Phone: 415-663-8781
  • Fax: 415-663-9630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateCA

VIII. Authorized Official

Name: RAFAEL GOMEZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 415-663-8781