Provider Demographics
NPI:1063439818
Name:COASTAL RADIOLOGY SERVICES, INC.
Entity type:Organization
Organization Name:COASTAL RADIOLOGY SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CANALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-429-7404
Mailing Address - Street 1:32332 CAMINO CAPISTRANO
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3701
Mailing Address - Country:US
Mailing Address - Phone:949-429-7404
Mailing Address - Fax:949-481-3209
Practice Address - Street 1:32332 CAMINO CAPISTRANO
Practice Address - Street 2:SUITE 205
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3701
Practice Address - Country:US
Practice Address - Phone:949-429-7404
Practice Address - Fax:949-481-3209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXR062500FMedicaid
CAR062500Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAXR062500FMedicaid