Healthcare Provider Details

I. General information

NPI: 1265681399
Provider Name (Legal Business Name): CHILDREN'S CENTRAL COAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2329 OAK PARK LN
SANTA BARBARA CA
93105-4280
US

IV. Provider business mailing address

3006 S MARYLAND PKWY SUITE 505
LAS VEGAS NV
89109-2218
US

V. Phone/Fax

Practice location:
  • Phone: 888-350-2911
  • Fax:
Mailing address:
  • Phone: 702-697-0082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DONNA MESSENGER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 888-350-2911