Provider Demographics
NPI:1568994028
Name:LAKEWOOD IPA
Entity Type:Organization
Organization Name:LAKEWOOD IPA
Other - Org Name:COAST HEALTHCARE MANAGEMENT, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-602-1563
Mailing Address - Street 1:10833 VALLEY VIEW ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-5046
Mailing Address - Country:US
Mailing Address - Phone:562-602-1563
Mailing Address - Fax:
Practice Address - Street 1:10833 VALLEY VIEW ST
Practice Address - Street 2:SUITE 300
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-5046
Practice Address - Country:US
Practice Address - Phone:562-602-1563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA011549OtherLICENSE #