Provider Demographics
NPI:1346570074
Name:LAGS SPINE & SPORTSCARE CENTRAL COAST MEDICAL INC
Entity Type:Organization
Organization Name:LAGS SPINE & SPORTSCARE CENTRAL COAST MEDICAL INC
Other - Org Name:LAGS WELLNESS & DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:P
Authorized Official - Last Name:LAGATTUTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-925-9581
Mailing Address - Street 1:201 N COLLEGE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4614
Mailing Address - Country:US
Mailing Address - Phone:805-925-9581
Mailing Address - Fax:805-925-5625
Practice Address - Street 1:201 N COLLEGE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4614
Practice Address - Country:US
Practice Address - Phone:805-925-9581
Practice Address - Fax:805-925-5625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-31
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC2476390OtherSTATE CORPORATION NUMBER
CAZZZ58838YOtherBLUESHIELD OF CA GROUP PROVIDER NUMBER
CA9538454OtherAETNA HEALTH -GROUP PROVIDER NUMBER
CACT861AMedicare PIN