Provider Demographics
NPI:1992977482
Name:COASTAL HEALTH LASER AESTHETICS
Entity type:Organization
Organization Name:COASTAL HEALTH LASER AESTHETICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-644-4809
Mailing Address - Street 1:501 W CHANNEL ISLANDS BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93041-2126
Mailing Address - Country:US
Mailing Address - Phone:805-815-4400
Mailing Address - Fax:805-815-4848
Practice Address - Street 1:501 W CHANNEL ISLANDS BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93041-2126
Practice Address - Country:US
Practice Address - Phone:805-815-4400
Practice Address - Fax:805-815-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26431174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty