=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336565894
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALIFORNIA COASTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2014
-----------------------------------------------------
Last Update Date | 03/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13488 MAXELLA AVE UNIT 311
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292-4300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-328-5231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13488 MAXELLA AVE 311
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292-4300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. YAVONNE ANDREA WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-328-5231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------