Provider Demographics
NPI:1982727293
Name:COASTAL SPORTS AND WELLNESS, INC
Entity Type:Organization
Organization Name:COASTAL SPORTS AND WELLNESS, INC
Other - Org Name:COASTAL SPORTS AND WELLNESS MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-678-0300
Mailing Address - Street 1:4010 SORRENTO VALLEY BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1405
Mailing Address - Country:US
Mailing Address - Phone:858-678-0300
Mailing Address - Fax:858-678-0915
Practice Address - Street 1:4010 SORRENTO VALLEY BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1405
Practice Address - Country:US
Practice Address - Phone:858-678-0300
Practice Address - Fax:858-678-0915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center