Provider Demographics
NPI:1083032262
Name:CALIFORNIA COASTAL DERMATOLOGY A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CALIFORNIA COASTAL DERMATOLOGY A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LITCHFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-294-1697
Mailing Address - Street 1:303 CALLE FRANCESCA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4507
Mailing Address - Country:US
Mailing Address - Phone:949-294-1697
Mailing Address - Fax:
Practice Address - Street 1:28261 MARGUERITE PKWY
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-3703
Practice Address - Country:US
Practice Address - Phone:949-294-1679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72814261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty