Healthcare Provider Details

I. General information

NPI: 1124579131
Provider Name (Legal Business Name): COUNTY OF SAN LUIS OBISPO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 BEECHWOOD DR
PASO ROBLES CA
93446-4730
US

IV. Provider business mailing address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

V. Phone/Fax

Practice location:
  • Phone: 805-769-1250
  • 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: M DAISY ILANO
Title or Position: MEDICAL DIRECTOR
Credential: M.D
Phone: 805-781-4700