MEDICARE: COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST, INC.

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	261QF0400X	Federally Qualified Health Center (FQHC)

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558540740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST, INC.

Provider Business Mailing Address
First Line	:	150 TEJAS PL
Second Line	:	PO BOX 430
City	:	NIPOMO
State	:	CA
Zip	:	93444-9123
Country	:	US
Telephone Number	:	805-929-3211
Fax Number	:	805-929-6440

Provider Business Practice Location Address
First Line	:	500 FIRST ST
Second Line	:
City	:	PASO ROBLES
State	:	CA
Zip	:	93446-3742
Country	:	US
Telephone Number	:	805-239-4222
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	RONALD E CASTLE
Credential	:
Telephone Number	:	805-929-3211

Provider Enumeration Date	:	10/24/2007
Last Update Date	:	11/18/2009

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