Basic Information
Provider Information | |||||||||
NPI: | 1316229289 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PACIFIC CENTRAL COAST HEALTH CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FRENCH HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 117 W BUNNY AVE | ||||||||
Address2: |   | ||||||||
City: | SANTA MARIA | ||||||||
State: | CA | ||||||||
PostalCode: | 934582805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8057393898 | ||||||||
FaxNumber: | 8056145932 | ||||||||
Practice Location | |||||||||
Address1: | 1941 JOHNSON AVE | ||||||||
Address2: | SUITE 301 | ||||||||
City: | SAN LUIS OBISPO | ||||||||
State: | CA | ||||||||
PostalCode: | 934014140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055976715 | ||||||||
FaxNumber: | 8055976716 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2011 | ||||||||
LastUpdateDate: | 11/12/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RICHARDSON | ||||||||
AuthorizedOfficialFirstName: | MATTHEW | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8057393108 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PACIFIC CENTRAL COAST HEALTH CENTERS | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
ID | Type | State | Issuer | Description | ZZZ06481Z | 01 |   | BSCA | OTHER |