=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154720373
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COAST PHYSICAL MEDICINE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2014
-----------------------------------------------------
Last Update Date | 08/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10956 WARNER AVE
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-3853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-963-0955
-----------------------------------------------------
Fax | 714-963-5775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17931 EUCLID ST
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-5409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-963-0955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARC CUBEIRO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 714-963-0955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------