Healthcare Provider Details

I. General information

NPI: 1881612828
Provider Name (Legal Business Name): COASTAL HEART, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 S BRISTOL ST STE 108
SANTA ANA CA
92704-5718
US

IV. Provider business mailing address

2621 S BRISTOL ST SUITE 108
SANTA ANA CA
92704-5718
US

V. Phone/Fax

Practice location:
  • Phone: 714-754-1684
  • Fax: 714-966-0417
Mailing address:
  • Phone: 714-754-1684
  • Fax: 714-966-0417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: REBECA E HERNANDEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 714-754-1684