Healthcare Provider Details

I. General information

NPI: 1972754448
Provider Name (Legal Business Name): PHS SAN CLEMENTE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 CAMINO DE LOS MARES SUITE 420
SAN CLEMENTE CA
92673-2835
US

IV. Provider business mailing address

675 CAMINO DE LOS MARES SUITE 420
SAN CLEMENTE CA
92673-2835
US

V. Phone/Fax

Practice location:
  • Phone: 949-496-2307
  • Fax: 949-496-8688
Mailing address:
  • Phone: 949-496-2307
  • Fax: 949-496-8688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN RAYMOND COLEMAN
Title or Position: PRESIDENT
Credential: AU.D.
Phone: 949-364-4361