MEDICARE: CENTRAL COAST VETERANS ASSOCIATES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251K00000X	Public Health or Welfare Agency
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1528695319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL COAST VETERANS ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	1890 DIABLO DRIVE
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93405-4762
Country	:	US
Telephone Number	:	805-459-2585
Fax Number	:	805-781-0525

Provider Business Practice Location Address
First Line	:	1890 DIABLO DRIVE
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93405-4762
Country	:	US
Telephone Number	:	805-459-2585
Fax Number	:	805-781-0525

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	BRIAN MICHAEL REES
Credential	:	MD
Telephone Number	:	805-459-2585

Provider Enumeration Date	:	03/24/2020
Last Update Date	:	03/25/2020

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