Healthcare Provider Details

I. General information

NPI: 1275735011
Provider Name (Legal Business Name): COASTAL COMMUNITIES PHYSICIAN NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 CASA ST STE 170
SAN LUIS OBISPO CA
93405-1887
US

IV. Provider business mailing address

4580 CALIFORNIA AVE
BAKERSFIELD CA
93309-1104
US

V. Phone/Fax

Practice location:
  • Phone: 805-549-0677
  • Fax: 805-549-7588
Mailing address:
  • Phone: 805-549-0677
  • Fax: 805-549-7588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number30221170
License Number StateCA

VIII. Authorized Official

Name: DR. JU HUAN LEE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 661-327-4411