Basic Information
| Provider Information | |||||||||
| NPI: | 1619453982 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEMORIAL HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | CENTRAL COAST CENTER FOR GYNECOLOGIC ONCOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5855 OLIVAS PARK DR | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930037672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056672801 | ||||||||
| FaxNumber: | 8056672865 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 LOMA VISTA RD STE 205 | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930032909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056525011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2018 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | WILDE | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8056525011 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY MEMORIAL HEALTH SYSTEM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
No ID Information.