Basic Information
| Provider Information | |||||||||
| NPI: | 1376731141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | COMMHLTHCNTRS,WOMEN'S HEALTH ATASCADERO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 TEJAS PL | ||||||||
| Address2: | PO BOX 430 | ||||||||
| City: | NIPOMO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934449123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059293211 | ||||||||
| FaxNumber: | 8059296440 | ||||||||
| Practice Location | |||||||||
| Address1: | 4555 EL CAMINO REAL | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934222700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054669001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2007 | ||||||||
| LastUpdateDate: | 10/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | CASTLE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8059293211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | FHC71030F | 05 | CA | MEDICAID |