=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700184025
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTLINE THERAPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2011
-----------------------------------------------------
Last Update Date | 03/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9535 RESEDA BLVD SUITE 301
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91324-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-718-1975
-----------------------------------------------------
Fax | 818-718-2259
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9535 RESEDA BLVD SUITE 301
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91324-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-718-1975
-----------------------------------------------------
Fax | 818-718-2259
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JONATHAN ESCOBAR
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 818-718-1975
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | DC25135
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------