Healthcare Provider Details

I. General information

NPI: 1760028336
Provider Name (Legal Business Name): ERIC RANDALL STOREY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2945 MCMILLAN AVE STE 240
SAN LUIS OBISPO CA
93401-6771
US

IV. Provider business mailing address

2945 MCMILLAN AVE
SAN LUIS OBISPO CA
93401-6766
US

V. Phone/Fax

Practice location:
  • Phone: 805-788-2507
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: