Healthcare Provider Details

I. General information

NPI: 1134287634
Provider Name (Legal Business Name): COUNTY OF SAN LUIS OBISPO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 02/21/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 4TH ST
PASO ROBLES CA
93446
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:
Mailing address:
  • Phone: 805-781-4700
  • Fax: 805-781-1273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health 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