Provider Demographics
NPI:1235383225
Name:INDUSTRIAL MEDICAL GROUP OF SANTA MARIA VALLEY
Entity Type:Organization
Organization Name:INDUSTRIAL MEDICAL GROUP OF SANTA MARIA VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUGHEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-922-8282
Mailing Address - Street 1:3070 SKYWAY DR STE 106
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1830
Mailing Address - Country:US
Mailing Address - Phone:805-922-8282
Mailing Address - Fax:805-925-2690
Practice Address - Street 1:3070 SKYWAY DR STE 106
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-1830
Practice Address - Country:US
Practice Address - Phone:805-922-8282
Practice Address - Fax:805-925-2690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50357261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine