Healthcare Provider Details

I. General information

NPI: 1487254413
Provider Name (Legal Business Name): COASTAL PRESTIGE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1677 SHELL BEACH RD
SHELL BEACH CA
93449-1927
US

IV. Provider business mailing address

1677 SHELL BEACH RD
SHELL BEACH CA
93449-1927
US

V. Phone/Fax

Practice location:
  • Phone: 805-416-2263
  • Fax: 805-201-9134
Mailing address:
  • Phone: 805-416-2263
  • Fax: 805-201-9134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHNNIE HAM
Title or Position: CEO
Credential: MD
Phone: 805-416-2263