Provider Demographics
NPI:1144762220
Name:CENTRAL COAST FOOT & ANKLE SPECIALISTS
Entity Type:Organization
Organization Name:CENTRAL COAST FOOT & ANKLE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:805-209-4400
Mailing Address - Street 1:71 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-5326
Mailing Address - Country:US
Mailing Address - Phone:805-209-4400
Mailing Address - Fax:805-209-4444
Practice Address - Street 1:71 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-5326
Practice Address - Country:US
Practice Address - Phone:805-209-4400
Practice Address - Fax:805-209-4444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1598389389Medicaid
CA1528412244OtherNPI INDIVIDUAL
CA1528412244Medicaid