Healthcare Provider Details

I. General information

NPI: 1427434679
Provider Name (Legal Business Name): COAST PEDIATRICS CARMEL VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5965 VILLAGE DRIVE, SUITE 201
SAN DIEGO CA
92130
US

IV. Provider business mailing address

5965 VILLAGE DRIVE, SUITE 201
SAN DIEGO CA
92130
US

V. Phone/Fax

Practice location:
  • Phone: 858-755-7337
  • Fax: 858-755-7338
Mailing address:
  • Phone: 858-755-7337
  • Fax: 858-755-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA55826
License Number StateCA

VIII. Authorized Official

Name: MRS. KELLY ANN CONLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 858-794-7337