Healthcare Provider Details

I. General information

NPI: 1265945182
Provider Name (Legal Business Name): COUNTY OF SAN LUIS OBISPO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 SANTA ROSA CREEK RD
CAMBRIA CA
93428-3524
US

IV. Provider business mailing address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

V. Phone/Fax

Practice location:
  • Phone: 805-927-7148
  • Fax:
Mailing address:
  • Phone: 805-781-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RACHAEL KOENIG
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 805-781-4720