Healthcare Provider Details

I. General information

NPI: 1427382811
Provider Name (Legal Business Name): CENTRAL COAST OTOLARYNGOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 S PALISADE DR SUITE 206
SANTA MARIA CA
93454-8904
US

IV. Provider business mailing address

116 S PALISADE DR STE 206
SANTA MARIA CA
93454-8904
US

V. Phone/Fax

Practice location:
  • Phone: 805-614-9250
  • Fax:
Mailing address:
  • Phone: 805-614-9250
  • Fax: 805-614-9260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELIZABETH WIKHOLM
Title or Position: OFFICE MANAGER
Credential:
Phone: 805-614-9250