MEDICARE: COASTSIDE INTEGRATIVE NATUROPATHIC MEDICAL GROUP

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	175F00000X	Naturopath
2	171100000X	Acupuncturist

General Provider Information

NPI Number	:	1609216340
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTSIDE INTEGRATIVE NATUROPATHIC MEDICAL GROUP

Provider Business Mailing Address
First Line	:	450 DONDEE ST
Second Line	:	SUITE 5
City	:	PACIFICA
State	:	CA
Zip	:	94044-3056
Country	:	US
Telephone Number	:	650-380-0089
Fax Number	:

Provider Business Practice Location Address
First Line	:	450 DONDEE ST
Second Line	:	SUITE 5
City	:	PACIFICA
State	:	CA
Zip	:	94044-3056
Country	:	US
Telephone Number	:	650-380-0089
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SARAH ROTHMAN
Credential	:	ND, L.AC
Telephone Number	:	650-380-0089

Provider Enumeration Date	:	06/26/2013
Last Update Date	:	06/26/2013

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