Provider Demographics
NPI:1700253556
Name:COASTSIDE HEALTH AND MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:COASTSIDE HEALTH AND MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-994-4444
Mailing Address - Street 1:1618 SULLIVAN AVE
Mailing Address - Street 2:#208
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-1967
Mailing Address - Country:US
Mailing Address - Phone:650-994-4444
Mailing Address - Fax:650-994-3051
Practice Address - Street 1:1618 SULLIVAN AVE
Practice Address - Street 2:#208
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-1967
Practice Address - Country:US
Practice Address - Phone:650-994-4444
Practice Address - Fax:650-994-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67810261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH18020Medicare UPIN