Provider Demographics
NPI:1073501870
Name:COUNTY OF SAN LUIS OBISPO
Entity Type:Organization
Organization Name:COUNTY OF SAN LUIS OBISPO
Other - Org Name:SAN LUIS OBISPO COUNTY MENTAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:M. DAISY
Authorized Official - Middle Name:
Authorized Official - Last Name:ILANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-781-4700
Mailing Address - Street 1:2178 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4535
Mailing Address - Country:US
Mailing Address - Phone:805-781-4700
Mailing Address - Fax:805-781-1273
Practice Address - Street 1:2178 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4535
Practice Address - Country:US
Practice Address - Phone:805-781-4700
Practice Address - Fax:805-781-1273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4000Medicaid
CACP065AMedicare PIN