Basic Information
| Provider Information | |||||||||
| NPI: | 1043360191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN LUIS OBISPO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5575 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054616060 | ||||||||
| FaxNumber: | 8054616061 | ||||||||
| Practice Location | |||||||||
| Address1: | 2178 JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054616060 | ||||||||
| FaxNumber: | 8054616061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CURTIS | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | THERAPIST III | ||||||||
| AuthorizedOfficialTelephone: | 8054616121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 603351 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.