Healthcare Provider Details

I. General information

NPI: 1629066071
Provider Name (Legal Business Name): COASTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 05/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 HEATHER CT
TEMPLETON CA
93465-9738
US

IV. Provider business mailing address

290 HEATHER CT
TEMPLETON CA
93465-9738
US

V. Phone/Fax

Practice location:
  • Phone: 805-434-3035
  • Fax: 805-434-3065
Mailing address:
  • Phone: 805-434-3035
  • Fax: 805-434-3065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number050000125
License Number StateCA

VIII. Authorized Official

Name: MS. MARIE MOYA
Title or Position: CONTROLLER
Credential:
Phone: 805-474-7010