MEDICARE: TRI CITY COASTAL MEDICAL GROUP, 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	302R00000X	Health Maintenance Organization

General Provider Information

NPI Number	:	1477142461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI CITY COASTAL MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	161 THUNDER DR STE 212
Second Line	:
City	:	VISTA
State	:	CA
Zip	:	92083-6052
Country	:	US
Telephone Number	:	760-941-7309
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 N EL CAMINO REAL STE A
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92058-1844
Country	:	US
Telephone Number	:	760-941-7309
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT OF FINANCE
Name	:	MRS. GRACE BENDER
Credential	:
Telephone Number	:	760-941-7309

Provider Enumeration Date	:	01/13/2021
Last Update Date	:	01/13/2021

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