Healthcare Provider Details

I. General information

NPI: 1295690527
Provider Name (Legal Business Name): COASTAL COMMUNITY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 N UNIVERSITY AVE STE 150
PROVO UT
84604-6636
US

IV. Provider business mailing address

3650 N UNIVERSITY AVE STE 150
PROVO UT
84604-6636
US

V. Phone/Fax

Practice location:
  • Phone: 702-809-2505
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AYUSHMAAN SRINIVASA
Title or Position: BOARD MEMBER
Credential:
Phone: 702-809-2505