Healthcare Provider Details

I. General information

NPI: 1376619262
Provider Name (Legal Business Name): CONEJO MEDICAL AND BREAST CARE CENTER A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3180 WILLOW LN STE 212
THOUSAND OAKS CA
91361-4990
US

IV. Provider business mailing address

3180 WILLOW LN STE 212
THOUSAND OAKS CA
91361-4990
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-3239
  • Fax: 805-497-3110
Mailing address:
  • Phone: 805-497-3239
  • Fax: 805-497-3110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number174400000X
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELE GHAUSSY
Title or Position: COO/PRACTICE MANAGER
Credential: MD
Phone: 805-990-4375