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General NPI Number Information
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NPI Number | 1578738324
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Entity Type | Organization
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Legal Business Name | COASTAL WELLNESS MEDICAL GROUP, INC
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Dates
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Enumeration Date | 04/23/2008
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Last Update Date | 04/28/2008
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Provider Practice Location Address
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Address Line | 292 POSADA LN SUITE A
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City | TEMPLETON
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State | CA
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Zip | 93465-4054
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Country | US
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Telephone | 805-434-5222
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Fax |
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Provider Business Mailing Address
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Address Line | 1310 LAS TABLAS RD SUITE 207
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City | TEMPLETON
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State | CA
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Zip | 93465-9737
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Country | US
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Telephone | 805-369-1305
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Fax | 805-369-1309
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHRISTOPHER T BRADBURN
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Credential | D.O
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Telephone | 805-434-5222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 20A7376
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License Number State | CA
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