Provider Demographics
NPI:1083869804
Name:CENTRAL COAST PEDIATRICS INC
Entity Type:Organization
Organization Name:CENTRAL COAST PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHRD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-549-0888
Mailing Address - Street 1:1320 LAS TABLAS RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-9711
Mailing Address - Country:US
Mailing Address - Phone:805-434-3796
Mailing Address - Fax:
Practice Address - Street 1:1320 LAS TABLAS RD
Practice Address - Street 2:SUITE D
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9711
Practice Address - Country:US
Practice Address - Phone:805-434-3796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL COAST PEDIATRICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-20
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059300Medicaid
CAW1309Medicare PIN