Healthcare Provider Details

I. General information

NPI: 1780198523
Provider Name (Legal Business Name): CENTRAL COAST PEDIATRIC SURGICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 11/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W PUEBLO ST
SANTA BARBARA CA
93105-4353
US

IV. Provider business mailing address

PO BOX 1359
SAN CLEMENTE CA
92674-1359
US

V. Phone/Fax

Practice location:
  • Phone: 805-879-4271
  • Fax:
Mailing address:
  • Phone: 949-492-3514
  • Fax: 949-366-2390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT C KANARD
Title or Position: OWNER
Credential: MD
Phone: 224-420-0879