Basic Information
| Provider Information | |||||||||
| NPI: | 1659554061 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTLINE PAIN CENTER | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928420009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145317730 | ||||||||
| FaxNumber: | 7145317793 | ||||||||
| Practice Location | |||||||||
| Address1: | 15606 BROOKHURST ST STE A | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926837582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145317730 | ||||||||
| FaxNumber: | 7145317793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2007 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | TRAN | ||||||||
| AuthorizedOfficialFirstName: | PHONG | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7145317730 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COASTLINE PAIN CENTER | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G74233 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.