Provider Demographics
NPI:1174927073
Name:COASTAL FAMILY DERMATOLOGY, PC
Entity type:Organization
Organization Name:COASTAL FAMILY DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:KILCLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-544-5567
Mailing Address - Street 1:990 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6309
Mailing Address - Country:US
Mailing Address - Phone:805-544-5567
Mailing Address - Fax:805-544-3265
Practice Address - Street 1:990 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6309
Practice Address - Country:US
Practice Address - Phone:805-554-5567
Practice Address - Fax:805-544-3265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72400207NS0135X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty