Provider Demographics
NPI:1073904025
Name:COASTAL HEALTH ALLIANCE
Entity Type:Organization
Organization Name:COASTAL HEALTH ALLIANCE
Other - Org Name:POINT REYES MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-663-8781
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:POINT REYES STATION
Mailing Address - State:CA
Mailing Address - Zip Code:94956-0910
Mailing Address - Country:US
Mailing Address - Phone:415-663-8781
Mailing Address - Fax:415-663-9632
Practice Address - Street 1:6350 SIR FRANCIS DRAKE BLVD.
Practice Address - Street 2:
Practice Address - City:SAN GERONIMO
Practice Address - State:CA
Practice Address - Zip Code:94963
Practice Address - Country:US
Practice Address - Phone:415-663-8666
Practice Address - Fax:415-663-9532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)