Provider Demographics
NPI:1255465712
Name:CENTRAL COAST ALLERGY & ASTHMA, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CENTRAL COAST ALLERGY & ASTHMA, A MEDICAL CORPORATION
Other - Org Name:HOLLISTER ALLERGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDEN
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:SHERMAN
Authorized Official - Last Name:PRAGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-637-1689
Mailing Address - Street 1:45 E SAN JOAQUIN ST
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-2903
Mailing Address - Country:US
Mailing Address - Phone:831-637-1689
Mailing Address - Fax:831-637-1680
Practice Address - Street 1:930B SUNSET DR BLDG 2
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-5603
Practice Address - Country:US
Practice Address - Phone:831-637-1689
Practice Address - Fax:831-637-1680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72539174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071130Medicaid
CAGR0071130Medicaid