Healthcare Provider Details

I. General information

NPI: 1124934856
Provider Name (Legal Business Name): CENTRAL COAST ORTHOPEDIC MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 OAK PARK BLVD STE 204
PISMO BEACH CA
93449-3400
US

IV. Provider business mailing address

862 MEINECKE AVE STE 100
SAN LUIS OBISPO CA
93405-3701
US

V. Phone/Fax

Practice location:
  • Phone: 805-473-4949
  • Fax: 805-473-1802
Mailing address:
  • Phone: 805-541-4600
  • Fax: 805-541-8716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MONICA LOPEZ
Title or Position: PRACTICE MANAGER
Credential:
Phone: 805-541-4600