Provider Demographics
NPI:1710338462
Name:LA COSTA HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:LA COSTA HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAHAMUD
Authorized Official - Middle Name:MAHAD
Authorized Official - Last Name:ABDI
Authorized Official - Suffix:
Authorized Official - Credentials:MASTER'S DEGREE
Authorized Official - Phone:619-865-3475
Mailing Address - Street 1:2817 ANTHONY LN S STE 106
Mailing Address - Street 2:
Mailing Address - City:ST ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2489
Mailing Address - Country:US
Mailing Address - Phone:612-788-4290
Mailing Address - Fax:612-788-4290
Practice Address - Street 1:2817 ANTHONY LN S STE 106
Practice Address - Street 2:
Practice Address - City:ST ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418-2489
Practice Address - Country:US
Practice Address - Phone:612-788-4290
Practice Address - Fax:612-788-4290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health