Provider Demographics
NPI:1831552850
Name:SUMMIT COASTAL LIVING
Entity type:Organization
Organization Name:SUMMIT COASTAL LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:B
Authorized Official - Last Name:RANDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-689-8880
Mailing Address - Street 1:PO BOX 2028
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-1028
Mailing Address - Country:US
Mailing Address - Phone:949-689-8880
Mailing Address - Fax:
Practice Address - Street 1:165 E WILSON ST # B
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1564
Practice Address - Country:US
Practice Address - Phone:949-689-8880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50412324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC50412OtherDR. KAMBIZ KARIMI