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General NPI Number Information
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NPI Number | 1649818626
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Entity Type | Organization
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Legal Business Name | CENTRAL COAST REGENERATIVE MEDICINE INC
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Dates
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Enumeration Date | 12/20/2019
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Last Update Date | 04/23/2021
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Provider Practice Location Address
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Address Line | 628 CALIFORNIA BLVD STE E
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-2548
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Country | US
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Telephone | 805-540-2010
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Fax |
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Provider Business Mailing Address
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Address Line | 628 CALIFORNIA BLVD STE E
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-2548
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Country | US
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Telephone | 805-540-2010
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Fax |
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Authorized Official
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Title or Position | OWNER, AUTHORIZED OFFICIAL
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Name | ELLEXIS E KHAN
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Credential |
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Telephone | 530-415-6549
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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