Healthcare Provider Details

I. General information

NPI: 1235129255
Provider Name (Legal Business Name): CENTRAL COAST SPINE AND PAIN MANAGEMENT CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S HALCYON RD SUITE 106
ARROYO GRANDE CA
93420-3872
US

IV. Provider business mailing address

PO BOX 160
ARROYO GRANDE CA
93421-0160
US

V. Phone/Fax

Practice location:
  • Phone: 805-473-3705
  • Fax: 805-473-4832
Mailing address:
  • Phone: 805-473-3705
  • Fax: 805-473-4832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number2709131
License Number StateCA

VIII. Authorized Official

Name: DR. ANDREW G. MONROY
Title or Position: DIRECTOR
Credential: M.D.
Phone: 805-473-3705