Provider Demographics
NPI:1932653565
Name:COASTAL PRIMARY CARE
Entity Type:Organization
Organization Name:COASTAL PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAZI
Authorized Official - Middle Name:
Authorized Official - Last Name:REZAI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:805-314-5542
Mailing Address - Street 1:18672 FLORIDA ST
Mailing Address - Street 2:302-B
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1925
Mailing Address - Country:US
Mailing Address - Phone:805-314-5542
Mailing Address - Fax:805-466-4229
Practice Address - Street 1:18672 FLORIDA ST
Practice Address - Street 2:302-B
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1925
Practice Address - Country:US
Practice Address - Phone:805-314-5542
Practice Address - Fax:805-466-4229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A12157261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1386962686OtherINDIVIDUAL NPI NUMBER