Provider Demographics
NPI:1013218007
Name:COASTLINE MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:COASTLINE MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHONG
Authorized Official - Middle Name:H
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-531-7730
Mailing Address - Street 1:PO BOX 9658
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92728-9658
Mailing Address - Country:US
Mailing Address - Phone:714-531-7730
Mailing Address - Fax:714-531-7793
Practice Address - Street 1:15606 BROOKHURST ST
Practice Address - Street 2:STE A
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-7581
Practice Address - Country:US
Practice Address - Phone:714-531-7730
Practice Address - Fax:714-531-7793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6505310001Medicare NSC