Basic Information
| Provider Information | |||||||||
| NPI: | 1790109692 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOLETA NEIGHBORHOOD CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 N MILPAS ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931032331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056177850 | ||||||||
| FaxNumber: | 8059638880 | ||||||||
| Practice Location | |||||||||
| Address1: | 334 S PATTERSON AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | GOLETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931112400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056177878 | ||||||||
| FaxNumber: | 8056177880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2014 | ||||||||
| LastUpdateDate: | 06/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | BREUNINGER | ||||||||
| AuthorizedOfficialFirstName: | TRULA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8056177851 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SANTA BARBARA NEIGHBORHOOD CLINICS | ||||||||
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| AuthorizedOfficialCredential: | MPH MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 550002691 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 550002691 | 01 | CA | CLINIC LICENSE | OTHER |