MEDICARE: COASTAL RADIOLOGY SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335V00000X	Portable X-ray and/or Other Portable Diagnostic Imaging Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063439818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL RADIOLOGY SERVICES, INC.

Provider Business Mailing Address
First Line	:	32332 CAMINO CAPISTRANO
Second Line	:	SUITE 205
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-3701
Country	:	US
Telephone Number	:	949-429-7404
Fax Number	:	949-481-3209

Provider Business Practice Location Address
First Line	:	32332 CAMINO CAPISTRANO
Second Line	:	SUITE 205
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-3701
Country	:	US
Telephone Number	:	949-429-7404
Fax Number	:	949-481-3209

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MARTIN A. CANALES
Credential	:
Telephone Number	:	949-429-7404

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	08/22/2020

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