Provider Demographics
NPI:1821636549
Name:COASTAL HOSPICE OF SOCAL INC
Entity Type:Organization
Organization Name:COASTAL HOSPICE OF SOCAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:SIMBULAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-310-3338
Mailing Address - Street 1:12465 LEWIS ST STE 206
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12465 LEWIS ST STE 206
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4657
Practice Address - Country:US
Practice Address - Phone:951-310-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417332057Medicaid