Healthcare Provider Details

I. General information

NPI: 1083869804
Provider Name (Legal Business Name): CENTRAL COAST PEDIATRICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 LAS TABLAS RD SUITE D
TEMPLETON CA
93465-9711
US

IV. Provider business mailing address

1320 LAS TABLAS RD SUITE D
TEMPLETON CA
93465-9711
US

V. Phone/Fax

Practice location:
  • Phone: 805-434-3796
  • Fax:
Mailing address:
  • Phone: 805-434-3796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHRD J MACIAS
Title or Position: PRES/CFO
Credential: MD
Phone: 805-549-0888