Basic Information
Provider Information | |||||||||
NPI: | 1386855393 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAN LUIS OBISPO COUNTY DRUG & ALCOHOL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3556 EL CAMINO REAL | ||||||||
Address2: |   | ||||||||
City: | ATASCADERO | ||||||||
State: | CA | ||||||||
PostalCode: | 934222532 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054616080 | ||||||||
FaxNumber: | 8054616114 | ||||||||
Practice Location | |||||||||
Address1: | 1028 PACIFIC ST | ||||||||
Address2: |   | ||||||||
City: | SAN LUIS OBISPO | ||||||||
State: | CA | ||||||||
PostalCode: | 934013651 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055443594 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | O'CONNOR | ||||||||
AuthorizedOfficialFirstName: | EUGENE | ||||||||
AuthorizedOfficialMiddleName: | PATRICK | ||||||||
AuthorizedOfficialTitleorPosition: | SPECIALIST II | ||||||||
AuthorizedOfficialTelephone: | 8054616233 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.