Basic Information
| Provider Information | |||||||||
| NPI: | 1871743435 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL COAST PATHOLOGY CONSULTANTS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 S HIGUERA ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934017462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055497461 | ||||||||
| FaxNumber: | 8055497463 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 S HIGUERA ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934017462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055497461 | ||||||||
| FaxNumber: | 8055497463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2008 | ||||||||
| LastUpdateDate: | 09/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | ROCHA | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8055497461 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 05D0643503 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.