Provider Demographics
NPI:1003577644
Name:CENTRAL CALIFORNIA MOVEMENT DISORDERS
Entity Type:Organization
Organization Name:CENTRAL CALIFORNIA MOVEMENT DISORDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BLUETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:415-378-1485
Mailing Address - Street 1:60 EL VIENTO
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2853
Mailing Address - Country:US
Mailing Address - Phone:415-378-1485
Mailing Address - Fax:
Practice Address - Street 1:320 JAMES WAY STE 210
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2875
Practice Address - Country:US
Practice Address - Phone:800-462-3732
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-05
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty