Provider Demographics
NPI:1659554061
Name:COASTLINE PAIN CENTER
Entity Type:Organization
Organization Name:COASTLINE PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHONG
Authorized Official - Middle Name:H
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-531-7730
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92842-0009
Mailing Address - Country:US
Mailing Address - Phone:714-531-7730
Mailing Address - Fax:714-531-7793
Practice Address - Street 1:15606 BROOKHURST ST STE A
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-7582
Practice Address - Country:US
Practice Address - Phone:714-531-7730
Practice Address - Fax:714-531-7793
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTLINE PAIN CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-07
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74233174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14811Medicare PIN