Provider Demographics
NPI:1619113248
Name:COASTAL VEIN AND COSMETIC CENTER
Entity Type:Organization
Organization Name:COASTAL VEIN AND COSMETIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-904-5594
Mailing Address - Street 1:62 CORPORATE PARK STE 120
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-3142
Mailing Address - Country:US
Mailing Address - Phone:949-701-3394
Mailing Address - Fax:949-748-8868
Practice Address - Street 1:62 CORPORATE PARK STE 120
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-3142
Practice Address - Country:US
Practice Address - Phone:949-701-3394
Practice Address - Fax:949-748-8868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-03
Last Update Date:2009-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86825202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty