MEDICARE: COAST PRESIDIO SURGERY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	G22919	CA

General Provider Information

NPI Number	:	1093158750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COAST PRESIDIO SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	225 W PUEBLO ST
Second Line	:	SUITE B
City	:	SANTA BARBARA
State	:	CA
Zip	:	93105-3804
Country	:	US
Telephone Number	:	805-682-4532
Fax Number	:	805-687-0724

Provider Business Practice Location Address
First Line	:	225 W PUEBLO ST
Second Line	:	SUITE B
City	:	SANTA BARBARA
State	:	CA
Zip	:	93105-3804
Country	:	US
Telephone Number	:	805-682-4532
Fax Number	:	805-687-0724

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GREGORY S KELLER
Credential	:	M.D.
Telephone Number	:	805-687-6408

Provider Enumeration Date	:	04/12/2013
Last Update Date	:	04/12/2013

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