Provider Demographics
NPI:1376619262
Name:CONEJO MEDICAL AND BREAST CARE CENTER A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CONEJO MEDICAL AND BREAST CARE CENTER A MEDICAL CORPORATION
Other - Org Name:CONEJO MEDICAL & BREAST CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:COO/PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:GHAUSSY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-990-4375
Mailing Address - Street 1:3180 WILLOW LN STE 212
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-4990
Mailing Address - Country:US
Mailing Address - Phone:805-497-3239
Mailing Address - Fax:805-497-3110
Practice Address - Street 1:3180 WILLOW LN STE 212
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-4990
Practice Address - Country:US
Practice Address - Phone:805-497-3239
Practice Address - Fax:805-497-3110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X174400000X
207Q00000X, 207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty