Basic Information
| Provider Information | |||||||||
| NPI: | 1558320143 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL COAST PATHOLOGY CONSULTANTS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CCPC CLINICAL LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8139 | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934038139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055497461 | ||||||||
| FaxNumber: | 8055497463 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 S HIGUERA ST | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934017462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055416033 | ||||||||
| FaxNumber: | 8055416116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 12/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | ROCHA | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 8055416033 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | GR0058760 | 05 | CA | MEDICAID | LAB43503F | 05 | CA | MEDICAID |