Basic Information
| Provider Information | |||||||||
| NPI: | 1841217882 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY HEALTH CENTERS MORRO BAY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| 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: | 660 HARBOR ST | ||||||||
| Address2: | |||||||||
| City: | MORRO BAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934421906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057718489 | ||||||||
| FaxNumber: | 8057718494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 01/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | CASTLE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8059293211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | BCP71032F | 01 | CA | CANCER DETECTION PROGRAM | OTHER | FHC71032F | 05 | CA | MEDICAID | HAP71032F | 01 | CA | FAMILY PLANNING | OTHER | ZZZ09363Z | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER |