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General NPI Number Information
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NPI Number | 1275735011
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Entity Type | Organization
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Legal Business Name | COASTAL COMMUNITIES PHYSICIAN NETWORK, INC.
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Dates
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Enumeration Date | 06/04/2007
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Last Update Date | 07/21/2015
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Provider Practice Location Address
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Address Line | 35 CASA ST STE 170
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93405-1887
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Country | US
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Telephone | 805-549-0677
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Fax | 805-549-7588
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Provider Business Mailing Address
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Address Line | 4580 CALIFORNIA AVE
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City | BAKERSFIELD
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State | CA
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Zip | 93309-1104
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Country | US
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Telephone | 805-549-0677
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Fax | 805-549-7588
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. JU HUAN LEE
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Credential | M.D.
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Telephone | 661-327-4411
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 30221170
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License Number State | CA
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