Healthcare Provider Details

I. General information

NPI: 1275165979
Provider Name (Legal Business Name): COASTAL REGENERATIVE ORTHOPEDICS & WELLNESS CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11772 SORRENTO VALLEY RD STE 100
SAN DIEGO CA
92121-1016
US

IV. Provider business mailing address

11772 SORRENTO VALLEY RD STE 100
SAN DIEGO CA
92121-1016
US

V. Phone/Fax

Practice location:
  • Phone: 858-221-4229
  • Fax: 858-345-4828
Mailing address:
  • Phone: 858-221-4229
  • Fax: 858-345-4828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA MARX
Title or Position: BILLER
Credential:
Phone: 714-308-4995