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General NPI Number Information
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NPI Number | 1487254413
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Entity Type | Organization
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Legal Business Name | COASTAL PRESTIGE CLINIC
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Dates
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Enumeration Date | 10/28/2020
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Last Update Date | 10/28/2020
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Provider Practice Location Address
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Address Line | 1677 SHELL BEACH RD
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City | SHELL BEACH
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State | CA
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Zip | 93449-1927
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Country | US
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Telephone | 805-416-2263
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Fax | 805-201-9134
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Provider Business Mailing Address
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Address Line | 1677 SHELL BEACH RD
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City | SHELL BEACH
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State | CA
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Zip | 93449-1927
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Country | US
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Telephone | 805-416-2263
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Fax | 805-201-9134
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Authorized Official
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Title or Position | CEO
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Name | DR. JOHNNIE HAM
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Credential | MD
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Telephone | 805-416-2263
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TF0000X
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Taxonomy Name | Family Psychologist
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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 | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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