=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821031675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL VASCULAR CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2006
-----------------------------------------------------
Last Update Date | 08/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2841 N VENTURA RD STE 200
-----------------------------------------------------
City | OXNARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93036-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-983-6233
-----------------------------------------------------
Fax | 805-983-2459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 OUTLET CENTER DRIVE SUITE 230
-----------------------------------------------------
City | OXNARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93036-6073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-983-6233
-----------------------------------------------------
Fax | 805-983-2459
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GREGORY K ALBAUGH
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 805-983-6233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A40288
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------