Healthcare Provider Details

I. General information

NPI: 1861698300
Provider Name (Legal Business Name): COUNTY OF SAN LUIS OBISPO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

IV. Provider business mailing address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-4700
  • Fax: 805-781-1273
Mailing address:
  • Phone: 805-781-4700
  • Fax: 805-781-1273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number02016035
License Number StateCA

VIII. Authorized Official

Name: DR. M. DAISY ILANO
Title or Position: MENTAL HEALTH DIRECTOR
Credential: M.D.
Phone: 805-781-4700