Provider Demographics
NPI:1053406454
Name:COAST NEUROSURGICAL ASSOCIATES A MEDICAL GROUP
Entity type:Organization
Organization Name:COAST NEUROSURGICAL ASSOCIATES A MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NICOLLE
Authorized Official - Middle Name:KRISTINE
Authorized Official - Last Name:GARNICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-424-3924
Mailing Address - Street 1:2888 LONG BEACH BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1570
Mailing Address - Country:US
Mailing Address - Phone:562-595-7696
Mailing Address - Fax:562-988-1559
Practice Address - Street 1:2888 LONG BEACH BLVD STE 240
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1570
Practice Address - Country:US
Practice Address - Phone:562-595-7696
Practice Address - Fax:562-988-1559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1053406454Medicaid