Provider Demographics
NPI:1508916628
Name:COASTSIDE FAMILY MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:COASTSIDE FAMILY MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:V
Authorized Official - Last Name:HARLESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-712-7330
Mailing Address - Street 1:225 CABRILLO HWY S STE 100A
Mailing Address - Street 2:
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019-1738
Mailing Address - Country:US
Mailing Address - Phone:650-712-7330
Mailing Address - Fax:650-726-9317
Practice Address - Street 1:225 CABRILLO HWY S STE 100A
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-1738
Practice Address - Country:US
Practice Address - Phone:650-712-7330
Practice Address - Fax:650-726-9317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70942FMedicaid
CACMM70942FMedicaid