Healthcare Provider Details

I. General information

NPI: 1285808733
Provider Name (Legal Business Name): CENTRAL COAST OBSTETRICS & GYNECOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 POSADA LANE SUITE 202
TEMPLETON CA
93405-1890
US

IV. Provider business mailing address

100 CASA STREET SUITE B
SAN LUIS OBISPO CA
93465-4060
US

V. Phone/Fax

Practice location:
  • Phone: 805-434-5497
  • Fax: 805-434-0917
Mailing address:
  • Phone: 805-548-0775
  • Fax: 805-548-0777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DANNY LEROY LICKNESS
Title or Position: PRESIDENT
Credential: MD
Phone: 805-544-8811