Healthcare Provider Details

I. General information

NPI: 1760858450
Provider Name (Legal Business Name): COAST TO COAST CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5195 HAMPSTED VILLAGE CENTER WAY SUITE 256
NEW ALBANY OH
43054-8331
US

IV. Provider business mailing address

5195 HAMPSTED VILLAGE CENTER WAY SUITE 256
NEW ALBANY OH
43054-8331
US

V. Phone/Fax

Practice location:
  • Phone: 614-855-9961
  • Fax:
Mailing address:
  • Phone: 614-855-9961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA64578
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA64578
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA64578
License Number StateCA

VIII. Authorized Official

Name: MR. MARK JAMES BOLTON
Title or Position: OWNER
Credential: MD
Phone: 614-855-9961