Provider Demographics
NPI:1477142461
Name:TRI CITY COASTAL MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:TRI CITY COASTAL MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-941-7309
Mailing Address - Street 1:161 THUNDER DR STE 212
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6052
Mailing Address - Country:US
Mailing Address - Phone:760-941-7309
Mailing Address - Fax:
Practice Address - Street 1:115 N EL CAMINO REAL STE A
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1844
Practice Address - Country:US
Practice Address - Phone:760-941-7309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREATER TRI CITIES IPA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization