Provider Demographics
NPI:1043623960
Name:CENTRAL COAST OTOLARYNGOLOGY
Entity Type:Organization
Organization Name:CENTRAL COAST OTOLARYNGOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WIKHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-614-9250
Mailing Address - Street 1:116 S PALISADE DR STE 206
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-8906
Mailing Address - Country:US
Mailing Address - Phone:805-614-9250
Mailing Address - Fax:
Practice Address - Street 1:116 S PALISADE DR STE 206
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-8906
Practice Address - Country:US
Practice Address - Phone:805-614-9250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13405261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty