Provider Demographics
NPI:1275165979
Name:COASTAL REGENERATIVE ORTHOPEDICS & WELLNESS CENTER INC.
Entity Type:Organization
Organization Name:COASTAL REGENERATIVE ORTHOPEDICS & WELLNESS CENTER INC.
Other - Org Name:COASTAL REGENERATIVE ORTHOPEDICS & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-308-4995
Mailing Address - Street 1:11772 SORRENTO VALLEY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1016
Mailing Address - Country:US
Mailing Address - Phone:858-221-4229
Mailing Address - Fax:858-345-4828
Practice Address - Street 1:11772 SORRENTO VALLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1016
Practice Address - Country:US
Practice Address - Phone:858-221-4229
Practice Address - Fax:858-345-4828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-10
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty