MEDICARE: COASTLINE SPINE AND PAIN CENTER LLC

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	207Q00000X	Family Medicine Physician
2	208VP0014X	Interventional Pain Medicine Physician

General Provider Information

NPI Number	:	1114792439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTLINE SPINE AND PAIN CENTER LLC

Provider Business Mailing Address
First Line	:	4626 MARTIN LUTHER KING JR WAY S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98108-2135
Country	:	US
Telephone Number	:	206-721-8000
Fax Number	:	979-256-0818

Provider Business Practice Location Address
First Line	:	4626 MARTIN LUTHER KING JR WAY S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98108-2135
Country	:	US
Telephone Number	:	206-721-8000
Fax Number	:	979-256-0818

Authorized Official
Title or Position	:	OWNER
Name	:	BAO N DINH
Credential	:	MD
Telephone Number	:	206-721-8000

Provider Enumeration Date	:	11/16/2023
Last Update Date	:	11/16/2023

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