Provider Demographics
NPI:1932300944
Name:WEST COAST ENDOCRINE A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:WEST COAST ENDOCRINE A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:562-988-0040
Mailing Address - Street 1:5500 E ATHERTON ST
Mailing Address - Street 2:SUITE 416
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-4016
Mailing Address - Country:US
Mailing Address - Phone:562-988-0040
Mailing Address - Fax:562-988-0041
Practice Address - Street 1:5500 E ATHERTON ST
Practice Address - Street 2:SUITE 416
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-4016
Practice Address - Country:US
Practice Address - Phone:562-988-0040
Practice Address - Fax:562-988-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW17025133N00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17025Medicare PIN