Healthcare Provider Details

I. General information

NPI: 1508182833
Provider Name (Legal Business Name): SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF SAN LUIS OBISPO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 MURRAY AVE
SAN LUIS OBISPO CA
93405-1806
US

IV. Provider business mailing address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8761
US

V. Phone/Fax

Practice location:
  • Phone: 805-546-7766
  • Fax: 805-546-7932
Mailing address:
  • Phone: 559-353-5700
  • Fax: 559-353-5708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DEVONNA M. KAJI
Title or Position: PRESIDENT & MEDICAL DIRECTOR
Credential: M.D.
Phone: 559-353-5700