Provider Demographics
NPI:1487254413
Name:COASTAL PRESTIGE CLINIC
Entity type:Organization
Organization Name:COASTAL PRESTIGE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-416-2263
Mailing Address - Street 1:1677 SHELL BEACH RD
Mailing Address - Street 2:
Mailing Address - City:SHELL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-1927
Mailing Address - Country:US
Mailing Address - Phone:805-416-2263
Mailing Address - Fax:805-201-9134
Practice Address - Street 1:1677 SHELL BEACH RD
Practice Address - Street 2:
Practice Address - City:SHELL BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-1927
Practice Address - Country:US
Practice Address - Phone:805-416-2263
Practice Address - Fax:805-201-9134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty