Healthcare Provider Details

I. General information

NPI: 1295290567
Provider Name (Legal Business Name): COASTAL FAMILY DERMATOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

892 AEROVISTA PL STE 120
SAN LUIS OBISPO CA
93401-8054
US

IV. Provider business mailing address

892 AEROVISTA PL STE 120
SAN LUIS OBISPO CA
93401-8054
US

V. Phone/Fax

Practice location:
  • Phone: 805-544-5567
  • Fax: 805-544-3265
Mailing address:
  • Phone: 805-544-5567
  • Fax: 805-544-3265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE DENISE KILCLINE
Title or Position: OWNER
Credential:
Phone: 805-544-5567