Basic Information
| Provider Information | |||||||||
| NPI: | 1962676775 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL COAST OBSTETRICS & GYNECOLOGY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CASA STREET | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934051893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055480775 | ||||||||
| FaxNumber: | 8055480777 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 CASA STREET | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934051890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055480775 | ||||||||
| FaxNumber: | 8055480777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2008 | ||||||||
| LastUpdateDate: | 06/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | LICKNESS | ||||||||
| AuthorizedOfficialFirstName: | DANNY | ||||||||
| AuthorizedOfficialMiddleName: | LEROY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8055448811 | ||||||||
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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 | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | GR0092003 | 05 | CA | MEDICAID |