Healthcare Provider Details

I. General information

NPI: 1538446869
Provider Name (Legal Business Name): COUNTY OF SAN LUIS OBISPO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 ATASCADERO RD
MORRO BAY CA
93442-1516
US

IV. Provider business mailing address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-4700
  • Fax: 805-781-1273
Mailing address:
  • Phone: 805-781-4700
  • Fax: 805-781-1273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: M. DAISY ILANO
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 805-781-4700