=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497746473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PISMO FAMILY PRACTICE MEDICAL CORPORATION A CA PROF MEDICAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2005
-----------------------------------------------------
Last Update Date | 01/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 575 PRICE ST SUITE 101
-----------------------------------------------------
City | PISMO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93449-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-773-0707
-----------------------------------------------------
Fax | 805-773-2051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 575 PRICE ST SUITE 101
-----------------------------------------------------
City | PISMO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93449-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-773-0707
-----------------------------------------------------
Fax | 805-773-2051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WENDY EVE WEISS
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 805-773-0707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 20A0436
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------