Basic Information
Provider Information | |||||||||
NPI: | 1265681399 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHILDREN'S CENTRAL COAST | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3006 S MARYLAND PKWY | ||||||||
Address2: | SUITE 505 | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891092218 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026970082 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2329 OAK PARK LN | ||||||||
Address2: |   | ||||||||
City: | SANTA BARBARA | ||||||||
State: | CA | ||||||||
PostalCode: | 931054280 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8883502911 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2008 | ||||||||
LastUpdateDate: | 04/09/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MESSENGER | ||||||||
AuthorizedOfficialFirstName: | DONNA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 8883502911 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
No ID Information.