Provider Demographics
NPI:1578738324
Name:COASTAL WELLNESS MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:COASTAL WELLNESS MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:T
Authorized Official - Last Name:BRADBURN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:805-434-5222
Mailing Address - Street 1:1310 LAS TABLAS RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-9737
Mailing Address - Country:US
Mailing Address - Phone:805-369-1305
Mailing Address - Fax:805-369-1309
Practice Address - Street 1:292 POSADA LN
Practice Address - Street 2:SUITE A
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4054
Practice Address - Country:US
Practice Address - Phone:805-434-5222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7376261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherAETNA
CA=========OtherPACIFICARE
CA=========OtherUNITED HEALTHCARE
CA=========OtherBLUE CROSS
CA=========OtherCIGAN