MEDICARE: COUNTY OF SAN LUIS OBISPO

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487714697
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTY OF SAN LUIS OBISPO

Provider Business Mailing Address
First Line	:	2178 JOHNSON AVE
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-4535
Country	:	US
Telephone Number	:	805-781-4700
Fax Number	:	805-781-1273

Provider Business Practice Location Address
First Line	:	277 SOUTH ST STE T
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-5039
Country	:	US
Telephone Number	:	805-781-4850
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	M. DAISY ILANO
Credential	:	M.D.
Telephone Number	:	805-781-4700

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	08/22/2013

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Directions to “COUNTY OF SAN LUIS OBISPO ” Practice Location

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