Provider Demographics
NPI:1124579131
Name:COUNTY OF SAN LUIS OBISPO
Entity Type:Organization
Organization Name:COUNTY OF SAN LUIS OBISPO
Other - Org Name:VIRGINIA PETERSON ELEMENTARY SCHOOL
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:M
Authorized Official - Middle Name:DAISY
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:
Practice Address - Street 1:2501 BEECHWOOD DR
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-4730
Practice Address - Country:US
Practice Address - Phone:805-769-1250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP065AMedicare PIN