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General NPI Number Information
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NPI Number | 1295690527
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Entity Type | Organization
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Legal Business Name | COASTAL COMMUNITY CENTER INC
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Dates
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Enumeration Date | 12/18/2025
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Last Update Date | 12/18/2025
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Provider Practice Location Address
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Address Line | 3650 N UNIVERSITY AVE STE 150
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City | PROVO
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State | UT
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Zip | 84604-6636
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Country | US
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Telephone | 702-809-2505
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Fax |
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Provider Business Mailing Address
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Address Line | 3650 N UNIVERSITY AVE STE 150
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City | PROVO
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State | UT
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Zip | 84604-6636
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | BOARD MEMBER
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Name | AYUSHMAAN SRINIVASA
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Credential |
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Telephone | 702-809-2505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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