Provider Demographics
NPI:1275553257
Name:COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST INC
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST INC
Other - Org Name:COMMUNITY HEALTH CENTERS SAN LUIS OBISPO
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:CASTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-361-8014
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:1551 BISHOP ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4635
Practice Address - Country:US
Practice Address - Phone:805-269-1350
Practice Address - Fax:805-269-1384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCP71031FOtherCANCER DETECTION PROGRAM
CAZZZ09365ZOtherBLUE SHIELD OF CALIFORNIA
CAFHC71031FMedicaid
CAHAP71031FOtherFAMILY PLANNING
CABCP71031FOtherCANCER DETECTION PROGRAM
CA551983Medicare Oscar/Certification