Healthcare Provider Details

I. General information

NPI: 1467383075
Provider Name (Legal Business Name): COASTAL CONNECTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 AVENIDA DEL MAR STE 207J
SAN CLEMENTE CA
92672-4078
US

IV. Provider business mailing address

209 AVENIDA DEL MAR STE 207J
SAN CLEMENTE CA
92672-4078
US

V. Phone/Fax

Practice location:
  • Phone: 949-533-3046
  • Fax: 949-288-6231
Mailing address:
  • Phone: 949-533-3046
  • Fax: 949-288-6231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL VILLARREAL
Title or Position: COO
Credential:
Phone: 949-533-3046