=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497135768
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE SURGICAL MEDICAL GROUP OF SANTA BARBARA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2015
-----------------------------------------------------
Last Update Date | 06/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 533 E MICHELTORENA ST SUITE 103
-----------------------------------------------------
City | SANTA BARBARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93103-2200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-564-8917
-----------------------------------------------------
Fax | 805-564-8915
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 533 E. MICHELTORENA ST. SUITE 103
-----------------------------------------------------
City | SANTA BARBARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93103-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-564-8917
-----------------------------------------------------
Fax | 805-564-8915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / OWNER
-----------------------------------------------------
Name | DR. WILLIAM HAROLD COULTER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 805-564-8917
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | C29906
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------