Basic Information
Provider Information
NPI: 1770699282
EntityType: 2
ReplacementNPI:  
OrganizationName: MISSION ORTHOPEDICS SURGERY AND SPORTS MEDICINE
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Mailing Information
Address1: PO BOX 50706
Address2:  
City: SANTA BARBARA
State: CA
PostalCode: 931500706
CountryCode: US
TelephoneNumber: 8059633336
FaxNumber: 8055643332
Practice Location
Address1: 1201 E OCEAN AVE
Address2: SUITE B
City: LOMPOC
State: CA
PostalCode: 934367081
CountryCode: US
TelephoneNumber: 8059633336
FaxNumber: 8055643332
Other Information
ProviderEnumerationDate: 08/21/2006
LastUpdateDate: 08/22/2020
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AuthorizedOfficialLastName: WELLBORN
AuthorizedOfficialFirstName: COLVIN
AuthorizedOfficialMiddleName: CLAY
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 8059633336
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207XX0005X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine

ID Information
IDTypeStateIssuerDescription
00G84666005CA MEDICAID


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