=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841164167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL DIABETES CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2025
-----------------------------------------------------
Last Update Date | 10/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 486 CONSTITUTION AVE
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93012-8529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-266-4103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 486 CONSTITUTION AVE
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93012-8529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-266-4103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER OPERATOR
-----------------------------------------------------
Name | CASSIDY ROBINSON
-----------------------------------------------------
Credential | BSN-RN, CDCES
-----------------------------------------------------
Telephone | 949-266-4103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------