Provider Demographics
NPI:1386748440
Name:COAST CENTER FOR ORTHOPEDIC AND ARTHROSCOPIC SURGERY LLC
Entity type:Organization
Organization Name:COAST CENTER FOR ORTHOPEDIC AND ARTHROSCOPIC SURGERY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-268-3566
Mailing Address - Street 1:5643 COPLEY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7903
Mailing Address - Country:US
Mailing Address - Phone:858-268-3566
Mailing Address - Fax:858-268-0430
Practice Address - Street 1:5643 COPLEY DR STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-7903
Practice Address - Country:US
Practice Address - Phone:858-268-3566
Practice Address - Fax:858-268-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000519261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S051414BMedicare PIN
S051414BMedicare PIN