Healthcare Provider Details

I. General information

NPI: 1679736987
Provider Name (Legal Business Name): COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 S MILLER ST SUITE 9
SANTA MARIA CA
93454-6923
US

IV. Provider business mailing address

150 TEJAS PL PO BOX 430
NIPOMO CA
93444-9123
US

V. Phone/Fax

Practice location:
  • Phone: 805-934-5400
  • Fax: 805-938-9207
Mailing address:
  • Phone: 805-929-3211
  • Fax: 805-929-6440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number550000721
License Number StateCA

VIII. Authorized Official

Name: MR. RONALD E CASTLE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 805-929-3211