Provider Demographics
NPI:1093843377
Name:CENTRAL COAST IMAGING, P.C.-RAYTEL MEDICAL IMAGING
Entity Type:Organization
Organization Name:CENTRAL COAST IMAGING, P.C.-RAYTEL MEDICAL IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FLANEGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-831-1112
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-0548
Mailing Address - Country:US
Mailing Address - Phone:800-367-1095
Mailing Address - Fax:860-298-6127
Practice Address - Street 1:21 SANTA ROSA ST
Practice Address - Street 2:SUITE 250
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1898
Practice Address - Country:US
Practice Address - Phone:800-367-1095
Practice Address - Fax:860-298-6127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0089800Medicaid
CAZZZ20606ZMedicare PIN