Provider Demographics
NPI:1699956839
Name:COASTAL HEALTH ALLIANCE
Entity type:Organization
Organization Name:COASTAL HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-663-8781
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:65 THIRD STREET, SUITE 17
Mailing Address - City:POINT REYES STATION
Mailing Address - State:CA
Mailing Address - Zip Code:94956-0910
Mailing Address - Country:US
Mailing Address - Phone:415-663-8781
Mailing Address - Fax:415-663-9630
Practice Address - Street 1:65 THIRD STREET, SUITE 17
Practice Address - Street 2:
Practice Address - City:POINT REYES STATION
Practice Address - State:CA
Practice Address - Zip Code:94956-0910
Practice Address - Country:US
Practice Address - Phone:415-663-8781
Practice Address - Fax:415-663-9630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP70434FMedicaid