=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932653565
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL PRIMARY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2016
-----------------------------------------------------
Last Update Date | 08/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18672 FLORIDA ST 302-B
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92648-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-314-5542
-----------------------------------------------------
Fax | 805-466-4229
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18672 FLORIDA ST 302-B
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92648-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-314-5542
-----------------------------------------------------
Fax | 805-466-4229
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KAZI REZAI
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 805-314-5542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 20A12157
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------