Basic Information
| Provider Information | |||||||||
| NPI: | 1811372600 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENEWMD COASTAL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6260 EL CAMINO REAL | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920091609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604762953 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6260 EL CAMINO REAL | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920091609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604762953 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2015 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | SLOWIK | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7608032253 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0011X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | G73008 | 01 | CA | STATE LICENSE NUMBER | OTHER |