Provider Demographics
NPI:1518101989
Name:COASTAL PRESTIGE MEDICAL SERVICES, INC
Entity Type:Organization
Organization Name:COASTAL PRESTIGE MEDICAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNIE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-201-9135
Mailing Address - Street 1:1677 SHELL BEACH RD
Mailing Address - Street 2:
Mailing Address - City:SHELL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-1927
Mailing Address - Country:US
Mailing Address - Phone:805-201-9135
Mailing Address - Fax:805-201-9134
Practice Address - Street 1:1677 SHELL BEACH RD
Practice Address - Street 2:
Practice Address - City:SHELL BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-1927
Practice Address - Country:US
Practice Address - Phone:805-201-9135
Practice Address - Fax:805-201-9134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90443261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care