Healthcare Provider Details

I. General information

NPI: 1255441358
Provider Name (Legal Business Name): COASTAL HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3419 STATE ROUTE ONE
STINSON BEACH CA
94970-0978
US

IV. Provider business mailing address

PO BOX 910
POINT REYES STATION CA
94956-0910
US

V. Phone/Fax

Practice location:
  • Phone: 415-868-9656
  • Fax: 415-868-2858
Mailing address:
  • Phone: 415-663-8781
  • Fax: 415-663-9632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number110000413
License Number StateCA

VIII. Authorized Official

Name: JOHN SEVERSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 415-663-8781