Provider Demographics
NPI:1992738496
Name:COASTAL VILLAGE PRIMARY CARE
Entity type:Organization
Organization Name:COASTAL VILLAGE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-773-7440
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93483-0428
Mailing Address - Country:US
Mailing Address - Phone:805-773-7440
Mailing Address - Fax:805-773-7448
Practice Address - Street 1:2 JAMES WAY
Practice Address - Street 2:SUITE 209
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-4976
Practice Address - Country:US
Practice Address - Phone:805-773-7440
Practice Address - Fax:805-773-7448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49080207Q00000X
CAA70251207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06670ZOtherBLUE SHIELD
CAZZZ06670ZOtherBLUE SHIELD
CAW16101Medicare PIN