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General NPI Number Information
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NPI Number | 1619113248
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Entity Type | Organization
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Legal Business Name | COASTAL VEIN AND COSMETIC CENTER
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Dates
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Enumeration Date | 01/03/2009
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Last Update Date | 01/03/2009
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Provider Practice Location Address
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Address Line | 62 CORPORATE PARK STE 120
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City | IRVINE
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State | CA
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Zip | 92606-3142
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Country | US
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Telephone | 949-701-3394
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Fax | 949-748-8868
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Provider Business Mailing Address
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Address Line | 62 CORPORATE PARK STE 120
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City | IRVINE
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State | CA
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Zip | 92606-3142
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Country | US
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Telephone | 949-701-3394
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Fax | 949-748-8868
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ELLEN TERESA SONG
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Credential | M.D.
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Telephone | 714-904-5594
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 202K00000X
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Taxonomy Name | Phlebology Physician
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License Number | A86825
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License Number State | CA
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