Healthcare Provider Details

I. General information

NPI: 1134294416
Provider Name (Legal Business Name): COASTSIDE CLINICAL LABORATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 GRAND AVE
SOUTH SAN FRANCISCO CA
94080-3635
US

IV. Provider business mailing address

2001 UNION ST SUITE 300
SAN FRANCISCO CA
94123-4114
US

V. Phone/Fax

Practice location:
  • Phone: 650-636-1286
  • Fax: 650-588-4164
Mailing address:
  • Phone: 415-447-6899
  • Fax: 415-447-6894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateCA

VIII. Authorized Official

Name: CATHY BROOKS
Title or Position: OFFICE MANAGER
Credential:
Phone: 650-636-1291