Provider Demographics
NPI:1932371838
Name:COASTAL IMAGING SERVICE
Entity Type:Organization
Organization Name:COASTAL IMAGING SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARTIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-278-5590
Mailing Address - Street 1:1180 OLYMPIC DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-3393
Mailing Address - Country:US
Mailing Address - Phone:951-278-5590
Mailing Address - Fax:951-272-9924
Practice Address - Street 1:62 SAINT CROIX
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-5195
Practice Address - Country:US
Practice Address - Phone:951-278-5590
Practice Address - Fax:951-272-9924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATG327261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATG327Medicare PIN
CAY00045Medicare UPIN