Healthcare Provider Details

I. General information

NPI: 1083671358
Provider Name (Legal Business Name): CENTRAL COAST FACIAL SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 POSADA LN SUITE B
TEMPLETON CA
93465-4055
US

IV. Provider business mailing address

295 POSADA LN SUITE B
TEMPLETON CA
93465-4055
US

V. Phone/Fax

Practice location:
  • Phone: 805-434-5960
  • Fax: 805-434-5963
Mailing address:
  • Phone: 805-434-5960
  • Fax: 805-434-5963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberFNP26330
License Number StateCA

VIII. Authorized Official

Name: DR. ROMAN P BUKACHEVSKY
Title or Position: MEMBER-MANAGER
Credential: M.D.
Phone: 805-434-5960