Healthcare Provider Details

I. General information

NPI: 1487858817
Provider Name (Legal Business Name): COY BRISCOE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E HIGHWAY 246 SUITE 300
BUELLTON CA
93427-9645
US

IV. Provider business mailing address

649 VELA WAY
LOMPOC CA
93436-1833
US

V. Phone/Fax

Practice location:
  • Phone: 805-688-6550
  • Fax:
Mailing address:
  • Phone: 805-717-1055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP09535
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: