Basic Information
Provider Information | |||||||||
NPI: | 1679736987 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMMUNITY HEALTH CENTERS, SANTA MARIA 3 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 1414 S MILLER ST | ||||||||
Address2: | SUITE 9 | ||||||||
City: | SANTA MARIA | ||||||||
State: | CA | ||||||||
PostalCode: | 934546923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8059345400 | ||||||||
FaxNumber: | 8059389207 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2008 | ||||||||
LastUpdateDate: | 07/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CASTLE | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8059293211 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 550000721 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | HAP70477F | 01 | CA | HEALTHY FAMILIES | OTHER | FHC70477F | 05 | CA |   | MEDICAID | W1508 | 01 | CA | MEDICARE | OTHER |