Basic Information
| Provider Information | |||||||||
| NPI: | 1194913921 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL COAST FAMILY CARE MEDICAL ASSOCIATES, INC | ||||||||
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| OtherOrganizationName: | CENTRAL COAST FAMILY CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 S PALISADE DR | ||||||||
| Address2: | SUITE 131 | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934548902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059252521 | ||||||||
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| Practice Location | |||||||||
| Address1: | 220 S PALISADE DR STE 104B | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934545931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059252521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2007 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | THEIS | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8053491227 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.