Healthcare Provider Details

I. General information

NPI: 1144400201
Provider Name (Legal Business Name): SAN LUIS OBISPO EYE ASSOCIATES, A MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 10/21/2022
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 TANK FARM RD
SAN LUIS OBISPO CA
93401-7077
US

IV. Provider business mailing address

234 HEATHER CT SUITE 102
TEMPLETON CA
93465-8765
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-3937
  • Fax:
Mailing address:
  • Phone: 805-434-5970
  • Fax: 805-434-5973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. CHRISTINA LYKENS
Title or Position: PRACTICE ADMINISTRATOR
Credential: COE
Phone: 805-781-3937