Healthcare Provider Details

I. General information

NPI: 1982727293
Provider Name (Legal Business Name): COASTAL SPORTS AND WELLNESS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 SORRENTO VALLEY BLVD SUITE 300
SAN DIEGO CA
92121-1405
US

IV. Provider business mailing address

4010 SORRENTO VALLEY BLVD SUITE 300
SAN DIEGO CA
92121-1405
US

V. Phone/Fax

Practice location:
  • Phone: 858-678-0300
  • Fax: 858-678-0915
Mailing address:
  • Phone: 858-678-0300
  • Fax: 858-678-0915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN MICHAEL MARTINEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 858-678-0300