MEDICARE: ETNYRE AND MIKUNI MEDICAL CORPORATION

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	207Q00000X	Family Medicine Physician	G074101	CA

General Provider Information

NPI Number	:	1922091487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETNYRE AND MIKUNI MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	301 S MILLER ST
Second Line	:	SUITE 214
City	:	SANTA MARIA
State	:	CA
Zip	:	93454-5205
Country	:	US
Telephone Number	:	805-349-1202
Fax Number	:	805-349-0974

Provider Business Practice Location Address
First Line	:	301 S MILLER ST
Second Line	:	SUITE 214
City	:	SANTA MARIA
State	:	CA
Zip	:	93454-5205
Country	:	US
Telephone Number	:	805-349-1202
Fax Number	:	805-349-0974

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. DIANA J. DAUGHERTY
Credential	:
Telephone Number	:	805-349-1202

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	11/03/2008

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