Basic Information
| Provider Information | |||||||||
| NPI: | 1104945831 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC CENTRAL COAST HEALTH CENTERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARIAN COMMUNITY CLINICS, GUADALUPE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 W BUNNY AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934582805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393890 | ||||||||
| FaxNumber: | 8053477697 | ||||||||
| Practice Location | |||||||||
| Address1: | 4723 W MAIN ST | ||||||||
| Address2: | SUITE H | ||||||||
| City: | GUADALUPE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934341787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053432004 | ||||||||
| FaxNumber: | 8053432267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 11/12/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICHARDSON | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8057393108 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PACIFIC CENTRAL COAST HEALTH CENTERS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 050000090 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | ZZZ06481Z | 01 | BLUE SHIELD OF CA | OTHER | RHM53926F | 05 | CA | MEDICAID |