Healthcare Provider Details

I. General information

NPI: 1093158750
Provider Name (Legal Business Name): COAST PRESIDIO SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 W PUEBLO ST SUITE B
SANTA BARBARA CA
93105-3804
US

IV. Provider business mailing address

225 W PUEBLO ST SUITE B
SANTA BARBARA CA
93105-3804
US

V. Phone/Fax

Practice location:
  • Phone: 805-682-4532
  • Fax: 805-687-0724
Mailing address:
  • Phone: 805-682-4532
  • Fax: 805-687-0724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberG22919
License Number StateCA

VIII. Authorized Official

Name: DR. GREGORY S KELLER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 805-687-6408