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)

General Provider Information

NPI Number	:	1770946840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST INC

Provider Business Mailing Address
First Line	:	2050 S BLOSSER RD
Second Line	:
City	:	SANTA MARIA
State	:	CA
Zip	:	93458-7310
Country	:	US
Telephone Number	:	805-361-8014
Fax Number	:	805-361-8097

Provider Business Practice Location Address
First Line	:	429 LESLIE ST
Second Line	:
City	:	LOS ALAMOS
State	:	CA
Zip	:	93440
Country	:	US
Telephone Number	:	805-249-8858
Fax Number	:	805-361-8097

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	RONALD E CASTLE
Credential	:
Telephone Number	:	805-361-8014

Provider Enumeration Date	:	04/05/2016
Last Update Date	:	04/05/2016

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