Basic Information
| Provider Information | |||||||||
| NPI: | 1184028797 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 CALLE ATAPANEO | ||||||||
| Address2: | |||||||||
| City: | NIPOMO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934447807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058017883 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 TEJAS PL | ||||||||
| Address2: | |||||||||
| City: | NIPOMO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934449123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059293254 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2014 | ||||||||
| LastUpdateDate: | 10/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | MALIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8059293254 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | 63651 | CA | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.