Healthcare Provider Details

I. General information

NPI: 1699758565
Provider Name (Legal Business Name): VENTANA HEALTH AND MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 OAK PARK BLVD SUITE 101
PISMO BEACH CA
93449-3216
US

IV. Provider business mailing address

PO BOX 1410
PISMO BEACH CA
93448-1410
US

V. Phone/Fax

Practice location:
  • Phone: 805-489-2205
  • Fax: 805-489-2206
Mailing address:
  • Phone: 805-489-2205
  • Fax: 805-489-2206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2537515
License Number StateCA

VIII. Authorized Official

Name: DR. MEGAN M ELLMAN
Title or Position: VP
Credential: MD
Phone: 805-489-2205